Provider Demographics
NPI:1972592152
Name:MALEC, WILLIAM ANDREW
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ANDREW
Last Name:MALEC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-6217
Mailing Address - Country:US
Mailing Address - Phone:731-422-3811
Mailing Address - Fax:731-422-5681
Practice Address - Street 1:201 E LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-6250
Practice Address - Country:US
Practice Address - Phone:731-422-3811
Practice Address - Fax:731-422-5681
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1173152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3598725Medicaid
TN3598725Medicare ID - Type Unspecified
TN3598725Medicaid