Provider Demographics
NPI:1164455978
Name:KAISERUDDIN, MOHAMMED ALTAF (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:ALTAF
Last Name:KAISERUDDIN
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 1:15628 CALYPSO LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5114
Mailing Address - Country:US
Mailing Address - Phone:708-620-8040
Mailing Address - Fax:
Practice Address - Street 1:2744 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2343
Practice Address - Country:US
Practice Address - Phone:773-434-4626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112300207Q00000X
WI45398-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI15147Medicare UPIN