Provider Demographics
NPI:1609862135
Name:MIRANZADEH, B FLORIAN (DO)
Entity Type:Individual
Prefix:
First Name:B FLORIAN
Middle Name:
Last Name:MIRANZADEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4793
Mailing Address - Country:US
Mailing Address - Phone:773-327-9900
Mailing Address - Fax:773-327-0589
Practice Address - Street 1:3718 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-4793
Practice Address - Country:US
Practice Address - Phone:773-327-9900
Practice Address - Fax:773-327-0589
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100398Medicaid
IL4010133OtherADVOCATE IL MASONIC
IL01629934OtherBCBS PROVIDER ID
IL080171110OtherRAILROAD MEDICARE
IL01629934OtherBCBS PROVIDER ID
ILL76988Medicare ID - Type UnspecifiedLOCALITY 16
IL080171110Medicare PIN
ILL76988Medicare PIN