Healthcare Provider Details

I. General information

NPI: 1538465307
Provider Name (Legal Business Name): TYRONDA ELLIOTT MALCOLM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 04/19/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST WING OA2 - ROOM 5
OAKLAND CA
94602
US

IV. Provider business mailing address

1411 E 31ST ST WING OA2, ROOM 5
OAKLAND CA
94602
US

V. Phone/Fax

Practice location:
  • Phone: 104-374-8005
  • Fax:
Mailing address:
  • Phone: 105-437-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA126934
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA126934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: