Provider Demographics
NPI:1043447774
Name:SOUDAGAR, ABDUS SAMAD (MD)
Entity type:Individual
Prefix:
First Name:ABDUS
Middle Name:SAMAD
Last Name:SOUDAGAR
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 1:396 REMINGTON BLVD
Mailing Address - Street 2:260
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:396 REMINGTON BLVD
Practice Address - Street 2:260
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4302
Practice Address - Country:US
Practice Address - Phone:630-312-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-21
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129936207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology