Provider Demographics
NPI:1962493395
Name:WALCHAK, ERIC THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:THOMAS
Last Name:WALCHAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:985 GEZON PKWY SW
Mailing Address - Street 2:ATTN: TERESA MCNALLY
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9563
Mailing Address - Country:US
Mailing Address - Phone:616-252-4655
Mailing Address - Fax:616-252-0103
Practice Address - Street 1:2122 HEALTH DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-5950
Practice Address - Fax:616-252-5956
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013546207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4618795Medicaid
MI5101013546OtherSTATE LICENSE
MIEW013546OtherBCBSM PIN
MIP00145080OtherRAILROAD MEDICARE
MI0D16078079Medicare PIN
MIEW013546OtherBCBSM PIN