Basic Information
| Provider Information | |||||||||
| NPI: | 1063668192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHMED | ||||||||
| FirstName: | IFFAT | ||||||||
| MiddleName: | SULTANA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1206 E 9TH ST | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604412404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309673470 | ||||||||
| FaxNumber: | 6302578388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-125768 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208342 | 01 | GROUP MEDICARE PTAN | OTHER |