Healthcare Provider Details

I. General information

NPI: 1538404827
Provider Name (Legal Business Name): MALIK EYE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4857 MANHATTAN DR
ROCKFORD IL
61108-2265
US

IV. Provider business mailing address

4857 MANHATTAN DR
ROCKFORD IL
61108-2265
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-0599
  • Fax: 815-399-2499
Mailing address:
  • Phone: 815-399-0599
  • Fax: 815-399-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036110588
License Number StateIL

VIII. Authorized Official

Name: MRS. RANAE D BERGMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-399-2190