Healthcare Provider Details

I. General information

NPI: 1942477658
Provider Name (Legal Business Name): MIR ASHAD ALI YADULLAHI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SOUTH CALIFORNIA AVENUE OS-551
CHICAGO IL
60608-1782
US

IV. Provider business mailing address

441 DELAWARE CIR
BOLINGBROOK IL
60440-1467
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6552
  • Fax:
Mailing address:
  • Phone: 630-414-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036122477
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number036122477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: