Provider Demographics
NPI:1114901501
Name:EHSAN, JAWED (MD)
Entity Type:Individual
Prefix:
First Name:JAWED
Middle Name:
Last Name:EHSAN
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:P O BOX 3412
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3412
Mailing Address - Country:US
Mailing Address - Phone:773-343-9844
Mailing Address - Fax:847-741-6588
Practice Address - Street 1:1100 LARKIN AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5272
Practice Address - Country:US
Practice Address - Phone:847-742-0165
Practice Address - Fax:847-742-0190
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532390OtherBCBS
IL04532181OtherBLUE CROSS BLUE SHIELD
P00090413OtherRAILROAD
209598OtherMEDICARE ID
P00090413OtherRAILROAD
IL04532390OtherBCBS
IL04532181OtherBLUE CROSS BLUE SHIELD