Healthcare Provider Details

I. General information

NPI: 1780797035
Provider Name (Legal Business Name): ALEKSANDER IVANOVICH MALAKHOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 411 SOUTH
BENTON TN
37307-0308
US

IV. Provider business mailing address

HIGHWAY 411 SOUTH
BENTON TN
37307-0308
US

V. Phone/Fax

Practice location:
  • Phone: 423-338-2831
  • Fax: 423-338-2833
Mailing address:
  • Phone: 423-338-2831
  • Fax: 423-338-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36698
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: