Healthcare Provider Details

I. General information

NPI: 1740227388
Provider Name (Legal Business Name): AYEZAH MIR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W JEFFERSON ST
SHOREWOOD IL
60404-7608
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 815-514-2040
  • Fax: 815-741-2860
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-112854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: