Provider Demographics
NPI:1114999430
Name:MALCOM, LATISHA M (MD)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:M
Last Name:MALCOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:28801 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2385
Mailing Address - Country:US
Mailing Address - Phone:734-266-2780
Mailing Address - Fax:734-466-9615
Practice Address - Street 1:6455 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1808
Practice Address - Country:US
Practice Address - Phone:313-921-8600
Practice Address - Fax:313-921-1712
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-05-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301070929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4604232-10Medicaid
MI4604232-10Medicaid
MIN94010011Medicare ID - Type Unspecified