Provider Demographics
NPI:1962729095
Name:MALPASS, ELISA JOY (MD)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:JOY
Last Name:MALPASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:JOY
Other - Last Name:LABENNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12997 WARWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-8352
Mailing Address - Country:US
Mailing Address - Phone:757-369-3357
Mailing Address - Fax:757-369-3587
Practice Address - Street 1:12997 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-8352
Practice Address - Country:US
Practice Address - Phone:757-369-3357
Practice Address - Fax:757-369-3587
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253831207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program