MEDICARE: INDIVIDUALIZED MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1962701722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIVIDUALIZED MEDICINE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 100
Second Line	:
City	:	ELKTON
State	:	FL
Zip	:	32033-0100
Country	:	US
Telephone Number	:	386-329-3939
Fax Number	:	386-329-8990

Provider Business Practice Location Address
First Line	:	6100 SAINT JOHNS AVE
Second Line	:	SUITE 4(D)
City	:	PALATKA
State	:	FL
Zip	:	32177-3844
Country	:	US
Telephone Number	:	386-329-3939
Fax Number	:	386-329-8990

Authorized Official
Title or Position	:	PRACTICE OWNER/PHYSICIAN
Name	:	DR. LARISA MALYKH
Credential	:	MD
Telephone Number	:	386-329-3939

Provider Enumeration Date	:	03/19/2011
Last Update Date	:	03/26/2012

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Directions to “INDIVIDUALIZED MEDICINE, LLC ” Practice Location

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