Provider Demographics
NPI:1053870915
Name:FAYYAZ, SANA (MD)
Entity type:Individual
Prefix:
First Name:SANA
Middle Name:
Last Name:FAYYAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-6271
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:815-455-2654
Practice Address - Street 1:525 E CONGRESS PKWY STE 350
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6271
Practice Address - Country:US
Practice Address - Phone:815-479-7490
Practice Address - Fax:815-455-2654
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036160812207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300026753Medicaid