Provider Demographics
NPI:1861486722
Name:KHAZEN, NINA W (MD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:W
Last Name:KHAZEN
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 1:3033 OGDEN AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1673
Mailing Address - Country:US
Mailing Address - Phone:630-717-5700
Mailing Address - Fax:630-717-0665
Practice Address - Street 1:3033 OGDEN AVE
Practice Address - Street 2:STE 101
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1673
Practice Address - Country:US
Practice Address - Phone:630-717-5700
Practice Address - Fax:630-717-0665
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104073Medicaid
IL036104073Medicaid
IL687165Medicare ID - Type Unspecified