Provider Demographics
NPI:1619210820
Name:MOHIUDDIN, SYED AZHAR (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:AZHAR
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 1:180 HARVESTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6686
Mailing Address - Country:US
Mailing Address - Phone:773-702-1150
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-834-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.063386207R00000X, 2085R0202X
IL036.1461192085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology