Individual
EWA K LACKA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5838 METRO WAY SW, WYOMING, MI 49519-9619
(269) 966-5600
Mailing address
5838 METRO WAY SW, WYOMING, MI 49519-9619
(269) 966-5600
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
4301067667
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
426712510
—
MI
01
—
700H262300
BLUE CROSS-BLUE CROSS
—
01
—
EL067767
CHAMPUS-CHAMPUS
—
Enumeration date
12/01/2006
Last updated
12/10/2025
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