Healthcare Provider Details

I. General information

NPI: 1184673147
Provider Name (Legal Business Name): JAMALUDDIN F AMANULLAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 BROADWAY ST LOWER LEVEL
PEKIN IL
61554-3905
US

IV. Provider business mailing address

2401 BROADWAY ST LOWER LEVEL
PEKIN IL
61554-3905
US

V. Phone/Fax

Practice location:
  • Phone: 314-971-5717
  • Fax: 309-620-8751
Mailing address:
  • Phone: 314-971-5717
  • Fax: 309-620-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number35084268
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2009011799
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036127585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: