Provider Demographics
NPI:1851398218
Name:FIDAI, GULZAR (MD)
Entity Type:Individual
Prefix:DR
First Name:GULZAR
Middle Name:
Last Name:FIDAI
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 1:1710 N RANDALL RD
Mailing Address - Street 2:380
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4902
Mailing Address - Country:US
Mailing Address - Phone:847-741-9800
Mailing Address - Fax:847-741-3058
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:380
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4902
Practice Address - Country:US
Practice Address - Phone:847-741-9800
Practice Address - Fax:847-741-3058
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085843208M00000X, 207R00000X
WI531208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085843Medicaid
ILF57773Medicare UPIN
ILL99395Medicare ID - Type Unspecified