Provider Demographics
NPI:1861630907
Name:KIZILBASH, ASAD (MD)
Entity Type:Individual
Prefix:
First Name:ASAD
Middle Name:
Last Name:KIZILBASH
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 1:4300 W LAKE AVE
Mailing Address - Street 2:208-B
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1474
Mailing Address - Country:US
Mailing Address - Phone:847-510-5734
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:MEDICAL EDUCATION DEPT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR29446207R00000X
IN01072237A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201164440Medicaid