Provider Demographics
NPI:1902917818
Name:AHMED, FAZAL (MD)
Entity Type:Individual
Prefix:
First Name:FAZAL
Middle Name:
Last Name:AHMED
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 1:1901 W HARRISON ST
Mailing Address - Street 2:ROOM # 3022
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3714
Mailing Address - Country:US
Mailing Address - Phone:312-864-6007
Mailing Address - Fax:312-864-9371
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:ROOM # 3022
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-6007
Practice Address - Fax:312-864-9371
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
IL036-1074302084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No174400000XOther Service ProvidersSpecialist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry