Provider Demographics
NPI:1750520888
Name:MALCOLM, JASMINE (MD)
Entity type:Individual
Prefix:DR
First Name:JASMINE
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 THOMAS JOHNSON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4569
Mailing Address - Country:US
Mailing Address - Phone:301-662-2000
Mailing Address - Fax:301-662-2500
Practice Address - Street 1:174 THOMAS JOHNSON DR STE 100
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4569
Practice Address - Country:US
Practice Address - Phone:301-662-2000
Practice Address - Fax:301-662-2500
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0073819208600000X
VA0101244373208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD331903200Medicaid
MD331903200Medicaid