MEDICARE: MALENA C SAMPLE M.D.

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	207V00000X	Obstetrics & Gynecology Physician	0101240370	VA

General Provider Information

NPI Number	:	1053323659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALENA C SAMPLE M.D.

Provider Business Mailing Address
First Line	:	5280 HENNEMAN DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-2503
Country	:	US
Telephone Number	:	757-395-4455
Fax Number	:	757-233-1792

Provider Business Practice Location Address
First Line	:	5280 HENNEMAN DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-2503
Country	:	US
Telephone Number	:	757-395-4455
Fax Number	:	757-233-1792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	11/05/2021

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Directions to “ MALENA C SAMPLE M.D.” Practice Location

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