Healthcare Provider Details

I. General information

NPI: 1942591433
Provider Name (Legal Business Name): QURAISH GHADIALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612
US

IV. Provider business mailing address

550 1ST AVE NYU LANGONE MEDICAL CENTER
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 212-263-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-142935
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036.142935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: