Provider Demographics
NPI:1194783878
Name:MALCOLM, BRADLEY S (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
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 1:105 RICHESON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2911
Mailing Address - Country:US
Mailing Address - Phone:434-385-7776
Mailing Address - Fax:434-385-5846
Practice Address - Street 1:105 RICHESON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2911
Practice Address - Country:US
Practice Address - Phone:434-385-7776
Practice Address - Fax:434-385-5846
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006793011Medicaid
VAF14073Medicare UPIN