Provider Demographics
NPI:1346256245
Name:DINI, KOUROSH (MD)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:DINI
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:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-0798
Mailing Address - Country:US
Mailing Address - Phone:847-692-6218
Mailing Address - Fax:847-692-5609
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1022
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-391-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361078982084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
01635637OtherBC/BS
IL036107898Medicaid
01635637OtherBC/BS
IL036107898Medicaid