Provider Demographics
NPI:1417964370
Name:ABBOUD, JAWDAT (MD)
Entity Type:Individual
Prefix:
First Name:JAWDAT
Middle Name:
Last Name:ABBOUD
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 1:2425 W.22ND STREET #205
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1934
Mailing Address - Country:US
Mailing Address - Phone:630-974-1400
Mailing Address - Fax:
Practice Address - Street 1:2425 W. 22ND ST. #205
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1934
Practice Address - Country:US
Practice Address - Phone:630-974-1400
Practice Address - Fax:188-846-6332
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087208261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087208Medicaid
IL45-4387283OtherTAX ID
IL036087208Medicaid
IL369700Medicare ID - Type Unspecified