Provider Demographics
NPI:1194737478
Name:LALKA, STEPHEN GARY (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GARY
Last Name:LALKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-355-8188
Mailing Address - Fax:704-355-8192
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-7481
Practice Address - Fax:313-876-1305
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01060208600000X, 2086S0129X
IN01035930A208600000X, 2086S0129X
MI43015004222086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0106AMedicaid
P00245249OtherRAILROAD MEDICARE
NC1396NOtherBCBS
NC1194737478Medicaid
NC5901224Medicaid
P00245249OtherRAILROAD MEDICARE
NC2042765Medicare PIN