Provider Demographics
NPI:1649652140
Name:GHAZIZADEH, RAMIN (DPM)
Entity type:Individual
Prefix:
First Name:RAMIN
Middle Name:
Last Name:GHAZIZADEH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 N LAKE SHORE DR APT 1421
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3475
Mailing Address - Country:US
Mailing Address - Phone:312-330-4574
Mailing Address - Fax:
Practice Address - Street 1:231 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2097
Practice Address - Country:US
Practice Address - Phone:708-748-3338
Practice Address - Fax:708-748-4332
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135000885213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005783Medicaid