Provider Demographics
NPI:1487867768
Name:FAZAL, SHAIROZ A (OD)
Entity Type:Individual
Prefix:
First Name:SHAIROZ
Middle Name:A
Last Name:FAZAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 BUTTERFIELD RD STE 111
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-8602
Mailing Address - Country:US
Mailing Address - Phone:630-480-8591
Mailing Address - Fax:630-480-8595
Practice Address - Street 1:811 E.BUTTERFIELD ROAD STE 111
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-480-8591
Practice Address - Fax:630-480-8595
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047932457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204953491OtherTAX ID