Provider Demographics
NPI:1326233081
Name:SHIRAZI, MOBEEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MOBEEN
Middle Name:A
Last Name:SHIRAZI
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 1:2441 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-6911
Mailing Address - Country:US
Mailing Address - Phone:815-338-4600
Mailing Address - Fax:815-338-4611
Practice Address - Street 1:2441 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-6911
Practice Address - Country:US
Practice Address - Phone:815-338-4600
Practice Address - Fax:815-338-4611
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28079207Y00000X, 207YS0123X
IL036116362207YX0905X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116362Medicaid
ILCN5830Medicare PIN
ILR03261Medicare PIN
IL036116362Medicaid