Basic Information
| Provider Information | |||||||||
| NPI: | 1841357621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALCZAK | ||||||||
| FirstName: | MAGDALENA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZACH | ||||||||
| OtherFirstName: | MAGDALENA | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 8778602291 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 SW EVERETT MALL WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253486727 | ||||||||
| FaxNumber: | 8778602291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD00036101 | WA | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | MD00036101 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01447969/DV4997 | 01 | WA | RAILROAD MEDICARE- EFF 1/13/14 | OTHER | 8225195 | 05 | WA | MEDICAID |