Provider Demographics
NPI:1316951510
Name:MALCOLM, SHIRLEY ANN (DO)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:DO
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-734-3430
Mailing Address - Fax:
Practice Address - Street 1:70 BOWER DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3689
Practice Address - Country:US
Practice Address - Phone:541-734-3430
Practice Address - Fax:541-512-1026
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO17513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057830Medicaid
ORF62603Medicare UPIN
ORR105060Medicare PIN