Provider Demographics
NPI:1962478370
Name:FOSTER, MALCOLM TENNYSON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:TENNYSON
Last Name:FOSTER
Suffix:JR
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP INTERNAL MEDICINE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3070
Practice Address - Fax:904-244-3087
Is Sole Proprietor?:No
Enumeration Date:2006-02-25
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME11138207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000273721AMedicaid
FL0571377-00Medicaid
FL0571377-00Medicaid
FLD61764Medicare UPIN
FL15347ZMedicare PIN