Provider Demographics
NPI:1962141895
Name:IMTIYAZ PASHA, UNKNOWN
Entity type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:IMTIYAZ PASHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IMTIYAZ
Other - Middle Name:
Other - Last Name:PASHA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSC
Mailing Address - Street 1:6759 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3220
Mailing Address - Country:US
Mailing Address - Phone:773-432-7187
Mailing Address - Fax:
Practice Address - Street 1:4539 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5618
Practice Address - Country:US
Practice Address - Phone:773-432-7187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D2557061OtherLICENSE