Healthcare Provider Details

I. General information

NPI: 1154389963
Provider Name (Legal Business Name): AMNA MIRZA MALIK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 S RANDALL RD
ALGONQUIN IL
60102-5915
US

IV. Provider business mailing address

10883 CONCORD LN
HUNTLEY IL
60142-4041
US

V. Phone/Fax

Practice location:
  • Phone: 847-458-5343
  • Fax: 847-458-4344
Mailing address:
  • Phone: 832-641-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010021
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: