Provider Demographics
NPI:1710203245
Name:MALCOLM MEDICAL GROUP
Entity Type:Organization
Organization Name:MALCOLM MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:408-246-9915
Mailing Address - Street 1:1150 SCOTT BLVD STE D1
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-4547
Mailing Address - Country:US
Mailing Address - Phone:408-246-9915
Mailing Address - Fax:408-246-0187
Practice Address - Street 1:1150 SCOTT BLVD STE D1
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-4547
Practice Address - Country:US
Practice Address - Phone:408-246-9915
Practice Address - Fax:408-246-0187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5858207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty