Healthcare Provider Details

I. General information

NPI: 1558582692
Provider Name (Legal Business Name): JOHN B MALCOLM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date: 02/13/2013
Reactivation Date: 03/27/2013

III. Provider practice location address

225 CLEARFIELD AVE
VIRGINIA BEACH VA
23462-1815
US

IV. Provider business mailing address

225 CLEARFIELD AVE
VIRGINIA BEACH VA
23462-1815
US

V. Phone/Fax

Practice location:
  • Phone: 757-457-5177
  • Fax: 757-452-3494
Mailing address:
  • Phone: 757-457-5177
  • Fax: 757-452-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101242814
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: