Healthcare Provider Details

I. General information

NPI: 1184679524
Provider Name (Legal Business Name): MOHAMED ADENWALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E BRUSH HILL RD STE 300
ELMHURST IL
60126-5659
US

IV. Provider business mailing address

133 E BRUSH HILL RD STE 300
ELMHURST IL
60126-5659
US

V. Phone/Fax

Practice location:
  • Phone: 630-571-1501
  • Fax: 630-571-5679
Mailing address:
  • Phone: 630-571-1501
  • Fax: 630-571-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-110825
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036.110825
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: