Healthcare Provider Details

I. General information

NPI: 1043230105
Provider Name (Legal Business Name): DAVID MALDONADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE SUITE 110
LANSING MI
48912-1800
US

IV. Provider business mailing address

1200 E MICHIGAN AVE SUITE 110
LANSING MI
48912-1800
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5875
  • Fax: 517-364-5877
Mailing address:
  • Phone: 517-364-5875
  • Fax: 517-364-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: