Provider Demographics
NPI:1710984224
Name:BOKHARI, SYED (MD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:
Last Name:BOKHARI
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 1:1615 N CONVENT ST
Mailing Address - Street 2:STE. 1
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1092
Mailing Address - Country:US
Mailing Address - Phone:815-937-5200
Mailing Address - Fax:815-937-2063
Practice Address - Street 1:1615 N CONVENT ST
Practice Address - Street 2:STE. 1
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1092
Practice Address - Country:US
Practice Address - Phone:815-937-5200
Practice Address - Fax:815-937-2063
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056192207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056192Medicaid
IL206759Medicare ID - Type Unspecified
IL036056192Medicaid