Provider Demographics
NPI:1043230857
Name:DAHODWALA, MOHAMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:DAHODWALA
Suffix:
Gender:M
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 64568
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-4568
Mailing Address - Country:US
Mailing Address - Phone:630-288-6200
Mailing Address - Fax:
Practice Address - Street 1:6441 S PULASKI RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:773-284-1234
Practice Address - Fax:773-284-1811
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065163207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065163Medicaid
IL01618378OtherBCBS PROVIDER ID
IL060053234OtherMEDICARE -- RR
IL01636774OtherBCBS PROVIDER ID
IL060053233OtherMEDICARE -- RR
IL060012282OtherRAILROAD MEDICARE
IL060012282OtherRAILROAD MEDICARE
ILK32450Medicare PIN
IL01618378OtherBCBS PROVIDER ID
IL01636774OtherBCBS PROVIDER ID
IL036065163Medicaid