Provider Demographics
NPI:1023343100
Name:MALCHOW, MICHELLE KAY (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:KAY
Last Name:MALCHOW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE 3RD AVENUE NE
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1667
Mailing Address - Country:US
Mailing Address - Phone:218-546-5108
Mailing Address - Fax:218-546-5736
Practice Address - Street 1:ONE 3RD AVENUE NE
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1667
Practice Address - Country:US
Practice Address - Phone:218-546-5108
Practice Address - Fax:218-546-5736
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3447152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502720040OtherMEDICARE PTAN
IL046010440Medicaid