Provider Demographics
NPI:1508895780
Name:TASHAKORI, MAHTAB (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHTAB
Middle Name:
Last Name:TASHAKORI
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:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-337-4105
Mailing Address - Fax:
Practice Address - Street 1:1802 SOUTH MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-326-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL834340OtherMEDICARE GROUP NUMBER
IL553180OtherMEDICARE GROUP NUMBER
IL834340OtherMEDICARE GROUP NUMBER
I42445Medicare UPIN
IL834340015Medicare PIN