Provider Demographics
NPI:1811079155
Name:MALKOVICH, DANA R (MD)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:R
Last Name:MALKOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1164
Mailing Address - Country:US
Mailing Address - Phone:218-879-1271
Mailing Address - Fax:218-879-8904
Practice Address - Street 1:417 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1164
Practice Address - Country:US
Practice Address - Phone:218-879-1271
Practice Address - Fax:218-879-8904
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM0102326OtherMEDICA
MN294395600Medicaid
MN52586MAOtherBLUES & FIRST PLAN
FM0102326OtherMEDICA
MND48795Medicare UPIN