Provider Demographics
NPI:1558582692
Name:MALCOLM, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
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 1:225 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1815
Mailing Address - Country:US
Mailing Address - Phone:757-457-5177
Mailing Address - Fax:757-452-3494
Practice Address - Street 1:225 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1815
Practice Address - Country:US
Practice Address - Phone:757-457-5177
Practice Address - Fax:757-452-3494
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-11-27
Deactivation Date:2013-02-13
Deactivation Code:
Reactivation Date:2013-03-27
Provider Licenses
StateLicense IDTaxonomies
VA0101242814208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558582692Medicaid
VA1558582692Medicaid