Provider Demographics
NPI:1497976831
Name:AMIRAHMADI, MODJTABA
Entity Type:Individual
Prefix:
First Name:MODJTABA
Middle Name:
Last Name:AMIRAHMADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7242
Mailing Address - Country:US
Mailing Address - Phone:312-413-3593
Mailing Address - Fax:
Practice Address - Street 1:1855 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7242
Practice Address - Country:US
Practice Address - Phone:312-413-3593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.117612207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACI3011OtherRAILROAD MEDICARE