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NPI Code Detail

MEDICARE: MICHAEL MALIVUK

MEDICARE: MICHAEL MALIVUK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry7155CO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17155OTHERCODENTAL LICENSE

General Provider Information

NPI Number : 1548480759
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL MALIVUK
Provider Business Mailing Address
First Line : 5780 N. CAREFREE CIRCLE
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80917
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5780 N CAREFREE CIR
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80917-2795
Country : US
Telephone Number : 719-597-9737
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/27/2007
Last Update Date : 07/08/2007

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