Healthcare Provider Details

I. General information

NPI: 1104110436
Provider Name (Legal Business Name): MAAJID MOHAMMED YUNUS EKKISWALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 08/14/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W STEPHENSON ST
FREEPORT IL
61032-4864
US

IV. Provider business mailing address

2638 SWANSON PKWY
ROCKFORD IL
61109-1879
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6000
  • Fax:
Mailing address:
  • Phone: 201-667-4754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT199826
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: