Provider Demographics
NPI:1659357382
Name:COLE, MALCOLM HENRY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:HENRY
Last Name:COLE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30264-1156
Mailing Address - Country:US
Mailing Address - Phone:770-253-0170
Mailing Address - Fax:770-253-0206
Practice Address - Street 1:931 LOWER FAYETTEVILLE RD STE J
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5790
Practice Address - Country:US
Practice Address - Phone:770-253-0170
Practice Address - Fax:770-253-0206
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2016-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA010505174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00112549AMedicaid