Provider Demographics
NPI:1962771667
Name:MCISAAC, MALCOLM C (MD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:C
Last Name:MCISAAC
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 1:205 ELMHURST DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2940
Mailing Address - Country:US
Mailing Address - Phone:716-662-4261
Mailing Address - Fax:
Practice Address - Street 1:205 ELMHURST DR
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2940
Practice Address - Country:US
Practice Address - Phone:716-662-4261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097349207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBM9595200OtherDEA