Provider Demographics
NPI:1699193268
Name:ETHEZAZ, MAHVEEN (MD)
Entity Type:Individual
Prefix:
First Name:MAHVEEN
Middle Name:
Last Name:ETHEZAZ
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 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:908 N ELM ST STE 103
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3635
Practice Address - Country:US
Practice Address - Phone:630-789-8890
Practice Address - Fax:630-789-8892
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-151954207Q00000X
MN61445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036151954Medicaid