Provider Demographics
NPI:1164925947
Name:CARSON, MALCOLM (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:
Last Name:CARSON
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 1:3629 RIDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1943
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-616-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2023-08-11
Deactivation Date:2018-03-17
Deactivation Code:
Reactivation Date:2018-04-04
Provider Licenses
StateLicense IDTaxonomies
GA96720208100000X
NY300740208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice