Provider Demographics
NPI:1184679524
Name:ADENWALLA, MOHAMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:ADENWALLA
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 1:133 E BRUSH HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5659
Mailing Address - Country:US
Mailing Address - Phone:630-571-1501
Mailing Address - Fax:630-571-5679
Practice Address - Street 1:133 E BRUSH HILL RD STE 300
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5659
Practice Address - Country:US
Practice Address - Phone:630-571-1501
Practice Address - Fax:630-571-5679
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.110825207WX0107X
IL036-110825207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110825Medicaid
ILP00366944OtherRR MEDICARE PIN
IL2201714OtherBCBS OF IL
ILI54981Medicare UPIN
ILP00366944OtherRR MEDICARE PIN
ILK28643Medicare PIN