Provider Demographics
NPI:1669848347
Name:SHAFIUDDIN, MOHAMMED
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:SHAFIUDDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4844 BUTTERFIELD ROAD
Mailing Address - Street 2:APT #2R
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162
Mailing Address - Country:US
Mailing Address - Phone:312-714-9744
Mailing Address - Fax:
Practice Address - Street 1:4844 BUTTERFIELD RD
Practice Address - Street 2:2R
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1462
Practice Address - Country:US
Practice Address - Phone:312-714-9744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS13554070015347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle