Provider Demographics
NPI:1902972516
Name:NIAZI, SHERAHSAN K (MD)
Entity Type:Individual
Prefix:
First Name:SHERAHSAN
Middle Name:K
Last Name:NIAZI
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 1:831 N LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3460
Mailing Address - Country:US
Mailing Address - Phone:815-741-8888
Mailing Address - Fax:815-730-3323
Practice Address - Street 1:831 N LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-741-8888
Practice Address - Fax:815-730-3323
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.11359R208000000X
IL036089109208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089109Medicaid
G10316Medicare UPIN