Healthcare Provider Details

I. General information

NPI: 1235545534
Provider Name (Legal Business Name): FARAZ AHMAD KHAN DAHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

IV. Provider business mailing address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-9541
  • Fax:
Mailing address:
  • Phone: 217-245-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301116619
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number2896
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036153011
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: