Provider Demographics
NPI:1992731616
Name:FAYYAZ, MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:FAYYAZ
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 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:1009 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3747
Practice Address - Country:US
Practice Address - Phone:312-996-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2044462-1207RG0100X
IL036.172365207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161000580OtherEMPIRE
NY00010053906OtherUNIVERA
NY000524018005OtherHEALTH NOW
NY01610186Medicaid
NY0407905OtherINDEPENDENT HEALTH
NY061127000096OtherFIDELIS
NY0407905OtherINDEPENDENT HEALTH