Provider Demographics
NPI:1902891948
Name:AL-KHUDARI, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:AL-KHUDARI
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 1:6201 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2701
Mailing Address - Country:US
Mailing Address - Phone:708-636-9393
Mailing Address - Fax:708-636-2022
Practice Address - Street 1:6201 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2701
Practice Address - Country:US
Practice Address - Phone:708-636-9393
Practice Address - Fax:708-636-2022
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103747207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103747Medicaid
IL120602OtherADVOCATE HLTH PARTNERS ID
IL56233132500OtherADVOCATE HLTH CENTERS ID
ILP00053534OtherRAILROAD MEDICARE
IL125181500OtherOWCP PROVIDER ID
IL0001633597OtherBCBS PROVIDER ID
IL5757720001Medicare NSC
IL0001633597OtherBCBS PROVIDER ID
ILDC1735Medicare PIN
IL125181500OtherOWCP PROVIDER ID