Provider Demographics
NPI:1912735226
Name:MALCOLM, BENJI D (MED)
Entity type:Individual
Prefix:
First Name:BENJI
Middle Name:D
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11345 S EGGLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4735
Mailing Address - Country:US
Mailing Address - Phone:773-499-2930
Mailing Address - Fax:
Practice Address - Street 1:11345 S EGGLESTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4735
Practice Address - Country:US
Practice Address - Phone:773-499-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty