Basic Information
| Provider Information | |||||||||
| NPI: | 1548568066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALAKA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | OKEOGHENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6416 DEANS HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERRIEN CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491029750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699854632 | ||||||||
| FaxNumber: | 2699854623 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699854632 | ||||||||
| FaxNumber: | 2699854623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301103741 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1548568066 | 05 | MI | MEDICAID |