Provider Demographics
NPI:1366428492
Name:MALCOLM, WILLIAM G (DPM)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SW 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3307
Mailing Address - Country:US
Mailing Address - Phone:954-804-2232
Mailing Address - Fax:305-865-0844
Practice Address - Street 1:4900 SW 101ST AVE
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33328-3307
Practice Address - Country:US
Practice Address - Phone:305-866-0268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2054213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390111400Medicaid
FL65144OtherBCBS
FLU01511Medicare UPIN
FL65144ZMedicare PIN