Provider Demographics
NPI:1114914272
Name:MALCOLM, ALBERT STAEBLER (MD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:STAEBLER
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3807
Mailing Address - Country:US
Mailing Address - Phone:513-423-0504
Mailing Address - Fax:513-423-9536
Practice Address - Street 1:235 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3807
Practice Address - Country:US
Practice Address - Phone:513-423-0504
Practice Address - Fax:513-423-9536
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055576174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0837572Medicaid
E89715Medicare UPIN
OH0695053Medicare ID - Type Unspecified