Provider Demographics
NPI:1861543985
Name:AHSAN, AZEEM MOHSIN (DO)
Entity type:Individual
Prefix:DR
First Name:AZEEM
Middle Name:MOHSIN
Last Name:AHSAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1640 WILLOW CIRCLE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60435-0959
Mailing Address - Country:US
Mailing Address - Phone:815-741-2525
Mailing Address - Fax:815-741-2522
Practice Address - Street 1:1640 WILLOW CIRCLE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60435-0959
Practice Address - Country:US
Practice Address - Phone:815-741-2525
Practice Address - Fax:815-741-2522
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
14DO713656OtherCLIA
633160Medicare PIN
L84427Medicare PIN
C46138Medicare UPIN
IL731642Medicare ID - Type Unspecified