Healthcare Provider Details

I. General information

NPI: 1528291283
Provider Name (Legal Business Name): AZLAN TARIQ D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 W COLLEGE DR
PALOS HEIGHTS IL
60463-1010
US

IV. Provider business mailing address

PO BOX 74008272
CHICAGO IL
60674-8272
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax: 702-977-1496
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number336.094099
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036132883
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerLICENSE NO
# 2
IdentifierP01418887
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: