Healthcare Provider Details

I. General information

NPI: 1104893296
Provider Name (Legal Business Name): IJAZ A MALIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 N 12TH ST SUITE 400
MILWAUKEE WI
53233
US

IV. Provider business mailing address

PO BOX 2040
MILWAUKEE WI
53201-2040
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-7653
  • Fax: 414-219-7676
Mailing address:
  • Phone: 414-219-7653
  • Fax: 414-219-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number32806-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32806
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: