Healthcare Provider Details

I. General information

NPI: 1376591958
Provider Name (Legal Business Name): ASHIR WAHAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19400 NORTH CREEK DRIVE
LYNWOOD IL
60411-8742
US

IV. Provider business mailing address

PO BOX 639295 DEPT 93394
CINCINNATI OH
45263-9295
US

V. Phone/Fax

Practice location:
  • Phone: 708-474-0410
  • Fax: 708-474-0328
Mailing address:
  • Phone: 248-434-6169
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036096993
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: