Provider Demographics
NPI:1285769968
Name:FIRDAUSI F. MAZDA, M.D.,S.C.
Entity type:Organization
Organization Name:FIRDAUSI F. MAZDA, M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FIRDAUSI
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAZDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-941-2646
Mailing Address - Street 1:PO BOX 66974
Mailing Address - Street 2:SLOT L
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60666-0974
Mailing Address - Country:US
Mailing Address - Phone:630-941-2646
Mailing Address - Fax:630-941-3464
Practice Address - Street 1:360 W BUTTERFIELD RD
Practice Address - Street 2:#245
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5068
Practice Address - Country:US
Practice Address - Phone:630-941-2646
Practice Address - Fax:630-941-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360534593Medicaid
ILD15984Medicare UPIN
IL636051Medicare ID - Type Unspecified
IL0360534593Medicaid