Provider Demographics
NPI:1548568066
Name:MALAKA, DAVID OKEOGHENE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:OKEOGHENE
Last Name:MALAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 DEANS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-9750
Mailing Address - Country:US
Mailing Address - Phone:269-985-4632
Mailing Address - Fax:269-985-4623
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-985-4632
Practice Address - Fax:269-985-4623
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103741207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1548568066Medicaid