Healthcare Provider Details

I. General information

NPI: 1710203245
Provider Name (Legal Business Name): MALCOLM MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 SCOTT BLVD STE D1
SANTA CLARA CA
95050-4547
US

IV. Provider business mailing address

1150 SCOTT BLVD STE D1
SANTA CLARA CA
95050-4547
US

V. Phone/Fax

Practice location:
  • Phone: 408-246-9915
  • Fax: 408-246-0187
Mailing address:
  • Phone: 408-246-9915
  • Fax: 408-246-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A5858
License Number StateCA

VIII. Authorized Official

Name: DR. JON M SCOTT
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 408-246-9915