Provider Demographics
NPI:1649223595
Name:FAYYAZ, GHAZALA (MD)
Entity Type:Individual
Prefix:
First Name:GHAZALA
Middle Name:
Last Name:FAYYAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1344
Mailing Address - Country:US
Mailing Address - Phone:773-465-4600
Mailing Address - Fax:734-465-4666
Practice Address - Street 1:1542 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1344
Practice Address - Country:US
Practice Address - Phone:773-465-4600
Practice Address - Fax:773-465-4666
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361136342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1669563789OtherBLUE CROSS BLUE SHIELD OF IL
IL036113634 - 2Medicaid
IL036113634 - 2Medicaid
IL214675 - K38696Medicare PIN
ILI34545Medicare UPIN
IL214674 - K38695Medicare PIN