Provider Demographics
NPI:1932355187
Name:MALKIN, ALEXIS G (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:G
Last Name:MALKIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-1129
Mailing Address - Country:US
Mailing Address - Phone:617-262-2030
Mailing Address - Fax:
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1274
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT2134152WL0500X
MDTA2134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417657000Medicaid
MD155698ZALTMedicare PIN