Provider Demographics
NPI:1790716967
Name:DAHSHE, JALAL (MD)
Entity Type:Individual
Prefix:DR
First Name:JALAL
Middle Name:
Last Name:DAHSHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12082 BLACKTHORNE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8118
Mailing Address - Country:US
Mailing Address - Phone:773-459-8227
Mailing Address - Fax:708-581-3936
Practice Address - Street 1:4817 W 83RD ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2790
Practice Address - Country:US
Practice Address - Phone:708-425-3135
Practice Address - Fax:708-425-6884
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088926207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088926Medicaid
IL01608243OtherBLUE CROSS
IL01639156OtherBLUE CROSS
ILIL8640Medicare PIN
IL213994Medicare PIN
IL216342Medicare PIN
ILG23440Medicare UPIN
ILK50362Medicare PIN
ILIL864001Medicare PIN