Provider Demographics
NPI:1649790627
Name:KHOSRAVI, HASAN (MD)
Entity type:Individual
Prefix:DR
First Name:HASAN
Middle Name:
Last Name:KHOSRAVI
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 1:808 S WOOD ST STE 380
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7300
Mailing Address - Country:US
Mailing Address - Phone:312-413-7448
Mailing Address - Fax:
Practice Address - Street 1:808 S WOOD ST STE 380
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7300
Practice Address - Country:US
Practice Address - Phone:312-413-7448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101902207N00000X
IL036.155306207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology