Provider Demographics
NPI:1477089969
Name:ALWAKKAA, HISHAM
Entity Type:Individual
Prefix:
First Name:HISHAM
Middle Name:
Last Name:ALWAKKAA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 CEDAR HILL LN
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4273
Mailing Address - Country:US
Mailing Address - Phone:203-212-7241
Mailing Address - Fax:
Practice Address - Street 1:2521 CEDAR HILL LN
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-4273
Practice Address - Country:US
Practice Address - Phone:203-212-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT70164208D00000X
IL0361636652085R0202X
IL1636552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice