Basic Information
| Provider Information | |||||||||
| NPI: | 1558582692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALCOLM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CLEARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575177 | ||||||||
| FaxNumber: | 7574523494 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CLEARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575177 | ||||||||
| FaxNumber: | 7574523494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/13/2013 | ||||||||
| NPIReactivationDate: | 03/27/2013 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0101242814 | VA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1558582692 | 05 | VA | MEDICAID |