Provider Demographics
NPI:1922043223
Name:MOEENUDDIN, ZOHRA F (MD)
Entity Type:Individual
Prefix:
First Name:ZOHRA
Middle Name:F
Last Name:MOEENUDDIN
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 1:320 E ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3172
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-495-8614
Practice Address - Street 1:320 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3172
Practice Address - Country:US
Practice Address - Phone:309-624-9690
Practice Address - Fax:309-624-9714
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061030A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
IN01061030BOtherCSR
IN200533760Medicaid
IL036113542Medicaid
11520388OtherCAQH
11520388OtherCAQH
11520388OtherCAQH