Provider Demographics
NPI:1578710562
Name:AHMAD, RIZWAN S (MD)
Entity Type:Individual
Prefix:
First Name:RIZWAN
Middle Name:S
Last Name:AHMAD
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 1:104 W 6TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2899
Mailing Address - Country:US
Mailing Address - Phone:815-673-5533
Mailing Address - Fax:815-673-2554
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2899
Practice Address - Country:US
Practice Address - Phone:815-673-5533
Practice Address - Fax:815-673-2554
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124179208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD28493OtherSTATE LICENSE