Healthcare Provider Details

I. General information

NPI: 1902891948
Provider Name (Legal Business Name): MOHAMMAD AL-KHUDARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 W 95TH ST
OAK LAWN IL
60453-2701
US

IV. Provider business mailing address

6201 W 95TH ST
OAK LAWN IL
60453-2701
US

V. Phone/Fax

Practice location:
  • Phone: 708-636-9393
  • Fax: 708-636-2022
Mailing address:
  • Phone: 708-636-9393
  • Fax: 708-636-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036103747
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: