Provider Demographics
NPI:1659514131
Name:MAHDAVINIA, MAHBOOBEH
Entity Type:Individual
Prefix:
First Name:MAHBOOBEH
Middle Name:
Last Name:MAHDAVINIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 117
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-6296
Mailing Address - Fax:312-563-2201
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 117
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-6296
Practice Address - Fax:312-563-2201
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-127466207R00000X, 207RA0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology