Provider Demographics
NPI:1861538712
Name:AHMAD, IJAZ (MD)
Entity type:Individual
Prefix:MR
First Name:IJAZ
Middle Name:
Last Name:AHMAD
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 1:9133 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3512
Mailing Address - Country:US
Mailing Address - Phone:773-375-3312
Mailing Address - Fax:773-375-2334
Practice Address - Street 1:9133 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3512
Practice Address - Country:US
Practice Address - Phone:773-375-3312
Practice Address - Fax:773-375-2334
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107581207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107581Medicaid
IL036-107581OtherLIC PHY