Provider Demographics
NPI:1043414097
Name:MOHAMMAD, FAZAL (MD)
Entity Type:Individual
Prefix:DR
First Name:FAZAL
Middle Name:
Last Name:MOHAMMAD
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 1:27 DENNISON DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1876
Mailing Address - Country:US
Mailing Address - Phone:630-664-9273
Mailing Address - Fax:
Practice Address - Street 1:27 DENNISON DR
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-1876
Practice Address - Country:US
Practice Address - Phone:630-664-9273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090321207Q00000X
IN01068409A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1043414097Medicaid
IN200988900Medicaid
IL$$$$$$$$$Medicaid
INM400040671Medicare PIN
IL$$$$$$$$$Medicaid