Provider Demographics
NPI:1114313210
Name:KHAZAEI, SHAYAN (MD)
Entity Type:Individual
Prefix:
First Name:SHAYAN
Middle Name:
Last Name:KHAZAEI
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 1:15 S MCHENRY RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6705
Mailing Address - Country:US
Mailing Address - Phone:847-618-0326
Mailing Address - Fax:847-618-0762
Practice Address - Street 1:5 KISH HOSPITAL DR STE 203
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9602
Practice Address - Country:US
Practice Address - Phone:630-933-4056
Practice Address - Fax:630-933-4057
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361505382084N0400X
CT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036150538OtherSTATE LICENSE