Provider Demographics
NPI:1578509089
Name:ROOT, MALCOLM (MD)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:
Last Name:ROOT
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 1:5523 W CYPRESS ST
Mailing Address - Street 2:STE 202
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1735
Mailing Address - Country:US
Mailing Address - Phone:813-356-0196
Mailing Address - Fax:813-356-0197
Practice Address - Street 1:1209 W SWANN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2639
Practice Address - Country:US
Practice Address - Phone:813-253-3007
Practice Address - Fax:813-253-2098
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 60118208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376662400Medicaid
14890ZMedicare ID - Type Unspecified
F24905Medicare UPIN