Provider Demographics
NPI:1417945437
Name:HEYDARI, AMIR J (MD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:J
Last Name:HEYDARI
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 1:10350 HALIGUS RD STE 220
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9585
Mailing Address - Country:US
Mailing Address - Phone:815-455-2752
Mailing Address - Fax:815-455-2789
Practice Address - Street 1:10350 HALIGUS RD STE 220
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9585
Practice Address - Country:US
Practice Address - Phone:815-455-2752
Practice Address - Fax:815-455-2789
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054524208D00000X
IL036090794208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090794Medicaid
CODR.0054524OtherSTATE LICENSE
IL036090794OtherSTATE LICENSE
ILL94273Medicare ID - Type UnspecifiedMEDICARE