Provider Demographics
NPI:1437138245
Name:MAZDA, FIRDAUSI F (MD)
Entity Type:Individual
Prefix:
First Name:FIRDAUSI
Middle Name:F
Last Name:MAZDA
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 1:360 W BUTTERFIELD RD
Mailing Address - Street 2:STE 245
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5068
Mailing Address - Country:US
Mailing Address - Phone:630-941-2646
Mailing Address - Fax:630-941-3464
Practice Address - Street 1:360 W BUTTERFIELD RD
Practice Address - Street 2:STE 245
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5068
Practice Address - Country:US
Practice Address - Phone:630-941-2646
Practice Address - Fax:630-941-3464
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-053459208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360534593Medicaid
ILD15984Medicare UPIN
IL0360534593Medicaid
IL636052Medicare PIN