Basic Information
| Provider Information | |||||||||
| NPI: | 1548440803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAZIR | ||||||||
| FirstName: | SHAHID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 NE CRESCENT AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616061901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 112 NE CRESCENT AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616061901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 57008431 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 036124816 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036124816 | 01 | IL | LICENSE | OTHER |