Provider Demographics
NPI:1447380902
Name:MALCOLM, DAVID B
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 PALMBROOK DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2938
Mailing Address - Country:US
Mailing Address - Phone:800-251-2011
Mailing Address - Fax:813-884-2594
Practice Address - Street 1:7711 PALMBROOK DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2938
Practice Address - Country:US
Practice Address - Phone:800-251-2011
Practice Address - Fax:813-884-2594
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP80000049412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE9027Medicare ID - Type Unspecified
FLX34378Medicare UPIN