Provider Demographics
NPI:1154389963
Name:MALIK, AMNA MIRZA (OD)
Entity type:Individual
Prefix:
First Name:AMNA
Middle Name:MIRZA
Last Name:MALIK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10883 CONCORD LN
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-4041
Mailing Address - Country:US
Mailing Address - Phone:832-641-3351
Mailing Address - Fax:
Practice Address - Street 1:750 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5915
Practice Address - Country:US
Practice Address - Phone:847-458-5343
Practice Address - Fax:847-458-4344
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010021Medicaid
IL046010021Medicaid