Healthcare Provider Details

I. General information

NPI: 1215972773
Provider Name (Legal Business Name): LUCY B MALKASIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LUCY B MESROBIAN

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 11TH ST S
WAHPETON ND
58075-4655
US

IV. Provider business mailing address

275 11TH ST S
WAHPETON ND
58075-4655
US

V. Phone/Fax

Practice location:
  • Phone: 701-642-2000
  • Fax: 701-671-4106
Mailing address:
  • Phone: 701-642-2000
  • Fax: 701-671-4106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4761
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27260
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: