Provider Demographics
NPI:1043298342
Name:MALICKE, DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MALICKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 NEW ENGLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-2818
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:5450 FORT ST
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4601
Practice Address - Country:US
Practice Address - Phone:734-671-3883
Practice Address - Fax:734-671-3546
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006437207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043298342Medicaid
MI1156338864OtherBCBS
MI1043298342Medicaid
MIQ24594169Medicare ID - Type UnspecifiedMHP OKW-SJMM
MI1156338864OtherBCBS
MIN87430009Medicare ID - Type UnspecifiedPEC SJMM (PHYSICIANS)