Provider Demographics
NPI:1669464301
Name:ZELASKO, PAMELA S (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:S
Last Name:ZELASKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4070 LAKE DR SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8294
Mailing Address - Country:US
Mailing Address - Phone:616-455-4114
Mailing Address - Fax:616-455-4454
Practice Address - Street 1:4070 LAKE DR SE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-455-4114
Practice Address - Fax:616-455-4454
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4092978Medicaid
MIM80080002Medicare PIN
MI4092978Medicaid