Healthcare Provider Details

I. General information

NPI: 1801626668
Provider Name (Legal Business Name): MR. SHIVAM MALHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date: 05/13/2025
Reactivation Date: 08/19/2026

III. Provider practice location address

7417 N KNOXVILLE AVE
PEORIA IL
61614-2019
US

IV. Provider business mailing address

7417 KNOXVILLE AVENUE
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 309-322-1220
  • Fax:
Mailing address:
  • Phone: 309-322-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037279
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: