Provider Demographics
NPI:1922004514
Name:MACIK, GREGORY M (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
Last Name:MACIK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WILLMAR AVE SW
Mailing Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-231-5000
Mailing Address - Fax:220-231-5067
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:220-231-5067
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN339M8MAOtherBCBS
MN22-02526OtherMEDICA/UNITED HEALTH CARE
MN2237465OtherAMERICA'S PPO
MN222010OtherCOLE MANAGED VISION CARE
MN650127300Medicaid
MNMN2973OtherEYEMED VISION CARE
MN650127300Medicaid
MN2237465OtherAMERICA'S PPO