Provider Demographics
NPI:1962588061
Name:AHMED, MOHAMMED SHUJAUDDIN (DO)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:SHUJAUDDIN
Last Name:AHMED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-575-5000
Mailing Address - Fax:630-491-5472
Practice Address - Street 1:396 REMINGTON BLVD STE 140
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4311
Practice Address - Country:US
Practice Address - Phone:630-495-9356
Practice Address - Fax:630-495-9357
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113939207R00000X, 207R00000X
IL036113939207RN0300X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL400280OtherMEDICARE GROUP PTAN
IL036113939Medicaid
ILP00669440Medicare PIN
IL400280OtherMEDICARE GROUP PTAN
ILK52274Medicare PIN
MN110011600Medicare PIN
ILR01716Medicare PIN