Provider Demographics
NPI:1285706754
Name:ALKHUDARI, AZZAM M (MD)
Entity type:Individual
Prefix:
First Name:AZZAM
Middle Name:M
Last Name:ALKHUDARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8S180 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5542
Mailing Address - Country:US
Mailing Address - Phone:630-590-5809
Mailing Address - Fax:630-246-3166
Practice Address - Street 1:5669 W 95TH ST STE 3A
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2382
Practice Address - Country:US
Practice Address - Phone:708-634-2627
Practice Address - Fax:630-246-3166
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113149207L00000X, 207LP2900X
NY002755207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPENDINGMedicaid
NVCY770ZMedicare PIN