Healthcare Provider Details

I. General information

NPI: 1356906135
Provider Name (Legal Business Name): BONIFACE B MALANGU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N EDWARD ST STE 2400
DECATUR IL
62526-4163
US

IV. Provider business mailing address

2300 N EDWARD ST STE 2400
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-2400
  • Fax: 217-876-2405
Mailing address:
  • Phone: 217-876-2400
  • Fax: 217-876-2405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR-12554
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036181954
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: