Healthcare Provider Details

I. General information

NPI: 1720182074
Provider Name (Legal Business Name): GULAM AE HAJAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GULAM AHMED HAJAT MD

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 S PULASKI RD
ALSIP IL
60803-1608
US

IV. Provider business mailing address

28 DEER PATH TRL
BURR RIDGE IL
60527-6324
US

V. Phone/Fax

Practice location:
  • Phone: 708-489-6200
  • Fax: 708-489-6249
Mailing address:
  • Phone: 630-272-4265
  • Fax: 708-489-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number336019374
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: