Provider Demographics
NPI:1326037029
Name:CHOUDRY, PERVAZ M (MD)
Entity Type:Individual
Prefix:
First Name:PERVAZ
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 1:5266 THORNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6395
Mailing Address - Country:US
Mailing Address - Phone:815-877-2587
Mailing Address - Fax:
Practice Address - Street 1:5266 THORNBERRY DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6395
Practice Address - Country:US
Practice Address - Phone:815-877-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35376207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIF86716Medicare UPIN