Provider Demographics
NPI:1619961778
Name:MALEC, THOMAS A (MD, PC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:MALEC
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 LAKESIDE DR SE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2931
Mailing Address - Country:US
Mailing Address - Phone:616-459-3564
Mailing Address - Fax:616-459-3868
Practice Address - Street 1:515 LAKESIDE DR SE
Practice Address - Street 2:SUITE 207
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2931
Practice Address - Country:US
Practice Address - Phone:616-459-3564
Practice Address - Fax:616-459-3868
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301026401207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1059530Medicaid
D91335Medicare UPIN
04156923Medicare ID - Type Unspecified