Provider Demographics
NPI:1447402425
Name:MALCOM, CHRISTOPHER JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JAMES
Last Name:MALCOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4519 ENTERPRISE WAY
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-8055
Mailing Address - Country:US
Mailing Address - Phone:208-455-7482
Mailing Address - Fax:208-455-7538
Practice Address - Street 1:4519 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-8055
Practice Address - Country:US
Practice Address - Phone:208-455-7482
Practice Address - Fax:208-455-7538
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-07442085R0202X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ817783Medicaid
AZZ159583Medicare PIN