Provider Demographics
NPI:1306810304
Name:MICHALCZAK, AGATA M (DO)
Entity type:Individual
Prefix:DR
First Name:AGATA
Middle Name:M
Last Name:MICHALCZAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AGATA
Other - Middle Name:M
Other - Last Name:LODEJ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:909 W MAPLE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017
Mailing Address - Country:US
Mailing Address - Phone:248-435-2028
Mailing Address - Fax:248-435-2099
Practice Address - Street 1:909 W MAPLE RD
Practice Address - Street 2:STE 100
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017
Practice Address - Country:US
Practice Address - Phone:248-435-2028
Practice Address - Fax:248-435-2099
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4430930Medicaid
080F319020OtherBCBS
MI0N48670003Medicare PIN
H07454Medicare UPIN