Provider Demographics
NPI:1801896261
Name:SHAMSHUDDIN, MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:SHAMSHUDDIN
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 1:27702 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1277
Mailing Address - Country:US
Mailing Address - Phone:708-862-7674
Mailing Address - Fax:708-862-1781
Practice Address - Street 1:6703 159TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1781
Practice Address - Country:US
Practice Address - Phone:708-342-3000
Practice Address - Fax:708-342-3060
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091936Medicaid
IL231199006OtherMEDICARE
ILP00760031OtherRRM
IL036091936Medicaid
ILG62376Medicare UPIN
IL405711Medicare PIN