Healthcare Provider Details

I. General information

NPI: 1023063419
Provider Name (Legal Business Name): AJAY R MALPANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD SUITE 280
NORMAL IL
61761-6286
US

IV. Provider business mailing address

2200 FORT JESSE RD SUITE 280
NORMAL IL
61761-6286
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-1788
  • Fax: 309-862-1302
Mailing address:
  • Phone: 309-452-1788
  • Fax: 309-862-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number36081598
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number36081598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: