Provider Demographics
NPI:1114014859
Name:SYDNOR, MALCOLM K (MD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:K
Last Name:SYDNOR
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:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL STREET
Practice Address - Street 2:RADIOLOGY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0470
Practice Address - Country:US
Practice Address - Phone:804-828-8262
Practice Address - Fax:804-828-6129
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012263732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010159288 541581185Medicaid
I31277Medicare UPIN
VA010159288 541581185Medicaid