Provider Demographics
NPI:1134161029
Name:MALAMISURA, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:MALAMISURA
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 1:510 CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-9999
Mailing Address - Country:US
Mailing Address - Phone:304-325-3666
Mailing Address - Fax:304-327-2497
Practice Address - Street 1:510 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-9999
Practice Address - Country:US
Practice Address - Phone:304-325-3666
Practice Address - Fax:304-327-2497
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2023-03-07
Deactivation Date:2019-04-04
Deactivation Code:
Reactivation Date:2019-04-10
Provider Licenses
StateLicense IDTaxonomies
WV11940174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
9383331OtherMEDICARE PTAN
9383331OtherMEDICARE PTAN
A72239Medicare UPIN
MA0532822Medicare PIN
WVAM1743764OtherDEA