Provider Demographics
NPI:1316141302
Name:MALCOLM P. DULOCK, MD
Entity type:Organization
Organization Name:MALCOLM P. DULOCK, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-456-8200
Mailing Address - Street 1:319 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2213
Mailing Address - Country:US
Mailing Address - Phone:678-456-8200
Mailing Address - Fax:678-456-8201
Practice Address - Street 1:319 CANTON RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2213
Practice Address - Country:US
Practice Address - Phone:678-456-8200
Practice Address - Fax:678-456-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013265174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7624OtherMEDICARE
GA1922198647OtherINDIVIDUAL NPI
GA1922198647OtherINDIVIDUAL NPI