Provider Demographics
NPI:1487669735
Name:MOAZZAM, FARNAZ NANI (MD)
Entity Type:Individual
Prefix:
First Name:FARNAZ
Middle Name:NANI
Last Name:MOAZZAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S 13TH ST
Mailing Address - Street 2:# I
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4936
Mailing Address - Country:US
Mailing Address - Phone:309-495-0200
Mailing Address - Fax:309-353-4380
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-495-0200
Practice Address - Fax:309-353-4380
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101798208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101798Medicaid
ILH91221Medicare UPIN
IL036101798Medicaid
ILIL1881002Medicare PIN