Provider Demographics
NPI:1790120145
Name:HARDY, MALCOLM WILLIAM, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:WILLIAM, GEORGE
Last Name:HARDY
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 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1593
Practice Address - Street 1:320 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2922
Practice Address - Country:US
Practice Address - Phone:509-525-5010
Practice Address - Fax:509-522-9448
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD607478844207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2082569Medicaid