Provider Demographics
NPI:1518166461
Name:MOHIUDDIN, MOHTASHAM MUHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHTASHAM
Middle Name:MUHAMMED
Last Name:MOHIUDDIN
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 1:5005 WARREN ST
Mailing Address - Street 2:UNIT 607
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2986
Mailing Address - Country:US
Mailing Address - Phone:718-440-1726
Mailing Address - Fax:
Practice Address - Street 1:6224 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60636-2324
Practice Address - Country:US
Practice Address - Phone:718-440-1826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244888207R00000X
MI4301091423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQMX000000098898OtherAETNA BETTER HEALTH
IL11827677OtherCAQH
IL036-126845Medicaid
IL036-126845Medicaid
ILFM1301996OtherDEA