Provider Demographics
NPI:1396917514
Name:LACY, MALKISHUANA MALKEIL (OD)
Entity type:Individual
Prefix:
First Name:MALKISHUANA
Middle Name:MALKEIL
Last Name:LACY
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 1:4444 W JEFFERSON BLVD
Mailing Address - Street 2:STE 614
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-4600
Mailing Address - Country:US
Mailing Address - Phone:214-333-3937
Mailing Address - Fax:214-331-2021
Practice Address - Street 1:4444 W JEFFERSON BLVD
Practice Address - Street 2:STE 614
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-4600
Practice Address - Country:US
Practice Address - Phone:214-333-3937
Practice Address - Fax:214-331-2021
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7205TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist