Provider Demographics
NPI:1578563912
Name:AZARAN, ABDOL (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDOL
Middle Name:
Last Name:AZARAN
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:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0219
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:15614 S HARLEM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4402
Practice Address - Country:US
Practice Address - Phone:708-481-4200
Practice Address - Fax:708-481-3302
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058380207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058380Medicaid
ILCE0254OtherRAILROAD MEDICARE GROUP
ILP00760044OtherRR MEDICARE
IL324853OtherMEDICARE GROUP
IL036058380Medicaid
IL752304Medicare PIN
IL110152223Medicare PIN
IL036058380Medicaid