Provider Demographics
NPI:1356492227
Name:BAHMANBEIGI, KHOJASTEH (MD)
Entity Type:Individual
Prefix:DR
First Name:KHOJASTEH
Middle Name:
Last Name:BAHMANBEIGI
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 1:849 W LAKESIDE PL APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6746
Mailing Address - Country:US
Mailing Address - Phone:773-275-8893
Mailing Address - Fax:
Practice Address - Street 1:7464 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1620
Practice Address - Country:US
Practice Address - Phone:847-316-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202649964OtherFEDERAL TAX ID
IL036111438Medicaid
IL212046Medicare ID - Type UnspecifiedMEDICARE NUMBER
ILIL1742009Medicare UPIN
IL202649964OtherFEDERAL TAX ID
ILIL1742Medicare PIN