Provider Demographics
NPI:1275715484
Name:CHOUDRY, SAMIULLAH M (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIULLAH
Middle Name:M
Last Name:CHOUDRY
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 1:1051 ESSINGTON RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2801
Mailing Address - Country:US
Mailing Address - Phone:815-773-0099
Mailing Address - Fax:815-773-0088
Practice Address - Street 1:1051 ESSINGTON RD
Practice Address - Street 2:SUITE 290
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2842
Practice Address - Country:US
Practice Address - Phone:815-773-0099
Practice Address - Fax:815-773-0088
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105476Medicaid
IL0009932044OtherBCBS
IL0009932044OtherBCBS