Provider Demographics
NPI:1720182074
Name:HAJAT, GULAM AE (MD)
Entity Type:Individual
Prefix:MR
First Name:GULAM
Middle Name:AE
Last Name:HAJAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:GULAM
Other - Middle Name:AHMED
Other - Last Name:HAJAT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:28 DEER PATH TRL
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6324
Mailing Address - Country:US
Mailing Address - Phone:630-272-4265
Mailing Address - Fax:708-489-6249
Practice Address - Street 1:11808 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-1608
Practice Address - Country:US
Practice Address - Phone:708-489-6200
Practice Address - Fax:708-489-6249
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336019374208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054708Medicaid
C43524Medicare UPIN
600420Medicare ID - Type Unspecified