Healthcare Provider Details

I. General information

NPI: 1720068695
Provider Name (Legal Business Name): FAZLUR R. ZAHURULLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N PERRYVILLE RD
ROCKFORD IL
61114-8011
US

IV. Provider business mailing address

3401 N PERRYVILLE RD
ROCKFORD IL
61114-8011
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax:
Mailing address:
  • Phone: 815-971-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036102836
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: