Provider Demographics
NPI:1053345868
Name:MALCOLM, DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:MALCOLM
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 1:508 OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2130
Mailing Address - Country:US
Mailing Address - Phone:805-748-5540
Mailing Address - Fax:
Practice Address - Street 1:911 SUNSET DR
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5602
Practice Address - Country:US
Practice Address - Phone:831-636-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61127791207P00000X
CAG61262207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ695ZMedicare PIN
CABQ635ZMedicare PIN
CAAQ695YMedicare PIN
E50540Medicare UPIN