Healthcare Provider Details

I. General information

NPI: 1194737478
Provider Name (Legal Business Name): STEPHEN GARY LALKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

PO BOX 601067
CHARLOTTE NC
28260-1067
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7481
  • Fax: 313-876-1305
Mailing address:
  • Phone: 704-355-8188
  • Fax: 704-355-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2005-01060
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01035930A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2005-01060
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01035930A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301500422
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: