Provider Demographics
NPI:1871577015
Name:MALINCHAK, MARIE LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LESLIE
Last Name:MALINCHAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 ELECTRIC RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6444
Mailing Address - Country:US
Mailing Address - Phone:540-904-7912
Mailing Address - Fax:540-904-7926
Practice Address - Street 1:3239 ELECTRIC RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6444
Practice Address - Country:US
Practice Address - Phone:540-904-7912
Practice Address - Fax:540-904-7926
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-055326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5612187Medicaid
VA5612187Medicaid
VAG59390Medicare UPIN