Healthcare Provider Details

I. General information

NPI: 1659170074
Provider Name (Legal Business Name): JACOB ROBERT MALAKISMAIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

117 DORSHIRE CT
SCHAUMBURG IL
60193-6142
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 847-732-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number125.087876
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: