Provider Demographics
NPI:1144432188
Name:SAMIRUDDIN, MOHAMMED (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
Last Name:SAMIRUDDIN
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:PO BOX 1897
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-8897
Mailing Address - Country:US
Mailing Address - Phone:630-279-9600
Mailing Address - Fax:630-279-9602
Practice Address - Street 1:622 N ADDISON RD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-1419
Practice Address - Country:US
Practice Address - Phone:630-279-9600
Practice Address - Fax:630-279-9602
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-122142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00858156OtherRAILROAD MEDICARE
IL036122142Medicaid
IL11928895OtherCAQH
IL14D1096717OtherCLIA
IL14D1096717OtherCLIA
IL14D1096717OtherCLIA