Provider Demographics
NPI:1366445769
Name:SULTANA-GALLICK, MARILYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYNN
Middle Name:
Last Name:SULTANA-GALLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29753 HOOVER RD
Mailing Address - Street 2:STE A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-8900
Mailing Address - Country:US
Mailing Address - Phone:586-573-4333
Mailing Address - Fax:586-573-2149
Practice Address - Street 1:29753 HOOVER RD
Practice Address - Street 2:STE A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8900
Practice Address - Country:US
Practice Address - Phone:586-573-4333
Practice Address - Fax:586-573-2149
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047297207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3336110Medicaid
MI1805005281OtherBLUE SHIELD OF MICHIGAN
MI33361100Medicaid
MI1805005281OtherBLUE SHIELD OF MICHIGAN