Provider Demographics
NPI:1902814957
Name:HAFEZ, WALID M (MD)
Entity Type:Individual
Prefix:
First Name:WALID
Middle Name:M
Last Name:HAFEZ
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 1:927 BROADWAY
Mailing Address - Street 2:STE 302
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301
Mailing Address - Country:US
Mailing Address - Phone:217-224-6423
Mailing Address - Fax:217-223-3641
Practice Address - Street 1:7645 WOLF RIVER CIR STE 100
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1751
Practice Address - Country:US
Practice Address - Phone:901-405-0275
Practice Address - Fax:901-405-0287
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360566092084N0400X
IL036.0566092084N0400X
TN633982084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056609Medicaid
IL036056609Medicaid
C44916Medicare UPIN
IL211041003Medicare PIN