Provider Demographics
NPI:1093437105
Name:KHADER, MOHAMMAD
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:KHADER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10912 CENTRAL AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2454
Mailing Address - Country:US
Mailing Address - Phone:708-737-9724
Mailing Address - Fax:
Practice Address - Street 1:7124 W 83RD ST UNIT C
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-4034
Practice Address - Country:US
Practice Address - Phone:708-424-0909
Practice Address - Fax:708-424-1715
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily