Provider Demographics
NPI:1295761484
Name:RIZWAN, SHAFEEQUR (MD)
Entity type:Individual
Prefix:
First Name:SHAFEEQUR
Middle Name:
Last Name:RIZWAN
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 1:1044 N FRANCISCO AVE
Mailing Address - Street 2:BUSINESS OFFICE, 3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2743
Mailing Address - Country:US
Mailing Address - Phone:773-292-7357
Mailing Address - Fax:773-278-3899
Practice Address - Street 1:331 W HARDING RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3209
Practice Address - Country:US
Practice Address - Phone:318-614-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130546Medicaid
LAI17669Medicare UPIN
LA4J063Medicare ID - Type Unspecified