Provider Demographics
NPI:1750728192
Name:ITANI, MALAK (MD)
Entity type:Individual
Prefix:DR
First Name:MALAK
Middle Name:
Last Name:ITANI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-7200
Mailing Address - Fax:314-747-4189
Practice Address - Street 1:510 S KINGSHIGHWAY BLVD
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1016
Practice Address - Country:US
Practice Address - Phone:314-362-7200
Practice Address - Fax:314-747-4189
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017043456207U00000X, 2085B0100X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200051946Medicaid