Provider Demographics
NPI:1154316073
Name:MALCOLM, DENIS MICHAEL (NP)
Entity Type:Individual
Prefix:MR
First Name:DENIS
Middle Name:MICHAEL
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 N HARBOR CITY BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6572
Mailing Address - Country:US
Mailing Address - Phone:321-253-0846
Mailing Address - Fax:
Practice Address - Street 1:1495 N HARBOR CITY BLVD STE E
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6572
Practice Address - Country:US
Practice Address - Phone:321-253-0846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX681173363LF0000X
FLARNP9321278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS76566Medicare UPIN