Provider Demographics
NPI:1861547416
Name:BACCHUS, MALCOLM D (MD)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:D
Last Name:BACCHUS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 S MCCARRAN BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6145
Mailing Address - Country:US
Mailing Address - Phone:775-824-8100
Mailing Address - Fax:775-824-8112
Practice Address - Street 1:6630 S MCCARRAN BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6135
Practice Address - Country:US
Practice Address - Phone:775-824-8100
Practice Address - Fax:775-824-8112
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2025-05-04
Deactivation Date:2019-07-17
Deactivation Code:
Reactivation Date:2019-08-13
Provider Licenses
StateLicense IDTaxonomies
NV34422084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016041Medicaid
NVVWCGZLMedicare ID - Type Unspecified
NV002016041Medicaid