Healthcare Provider Details

I. General information

NPI: 1528387149
Provider Name (Legal Business Name): MEHWISH MOKTADER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6326 CERMAK RD
BERWYN IL
60402
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 708-303-9234
  • Fax: 773-729-2074
Mailing address:
  • Phone: 305-628-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036148200
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: