Provider Demographics
NPI:1578515409
Name:ASADULLAH, KHAJA (MD)
Entity Type:Individual
Prefix:DR
First Name:KHAJA
Middle Name:
Last Name:ASADULLAH
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 1:1480 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5314
Mailing Address - Country:US
Mailing Address - Phone:815-464-7212
Mailing Address - Fax:815-464-7251
Practice Address - Street 1:10181 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1274
Practice Address - Country:US
Practice Address - Phone:815-464-7212
Practice Address - Fax:815-464-7251
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099650Medicaid
H17804Medicare UPIN
IL036099650Medicaid
IL110228457Medicare PIN