Healthcare Provider Details

I. General information

NPI: 1447507363
Provider Name (Legal Business Name): M RAHMAN, D.O., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 N BROADWAY ST
CHICAGO IL
60640-1703
US

IV. Provider business mailing address

5457 N BROADWAY ST
CHICAGO IL
60640-1703
US

V. Phone/Fax

Practice location:
  • Phone: 773-409-4292
  • Fax: 773-409-4298
Mailing address:
  • Phone: 773-409-4292
  • Fax: 773-409-4298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036128847
License Number StateIL

VIII. Authorized Official

Name: DR. MALEKA P RAHMAN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 773-409-4292