Healthcare Provider Details

I. General information

NPI: 1285892455
Provider Name (Legal Business Name): GAUTAM MALIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2008
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3043 N WILTON AVE 2ND FLOOR
CHICAGO IL
60657
US

IV. Provider business mailing address

35318 EAGLE WAY
CHICAGO IL
60678-1353
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5424
  • Fax: 773-296-5280
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036-128378
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-128378
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME143824
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: