Provider Demographics
NPI:1841357621
Name:WALCZAK, MAGDALENA M (MD)
Entity type:Individual
Prefix:DR
First Name:MAGDALENA
Middle Name:M
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAGDALENA
Other - Middle Name:M
Other - Last Name:ZACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-860-2291
Practice Address - Street 1:15 SW EVERETT MALL WAY
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-2715
Practice Address - Country:US
Practice Address - Phone:425-348-6727
Practice Address - Fax:877-860-2291
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036101208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01447969/DV4997OtherRAILROAD MEDICARE- EFF 1/13/14
WA8225195Medicaid
WAP01447969/DV4997OtherRAILROAD MEDICARE- EFF 1/13/14
G70178Medicare UPIN