Provider Demographics
NPI:1952807661
Name:KAZEROONI, YASAMAN (MD)
Entity type:Individual
Prefix:
First Name:YASAMAN
Middle Name:
Last Name:KAZEROONI
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 1:1001 MAIN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2036
Mailing Address - Country:US
Mailing Address - Phone:309-691-4005
Mailing Address - Fax:309-691-6144
Practice Address - Street 1:1001 MAIN ST STE 400
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2036
Practice Address - Country:US
Practice Address - Phone:309-691-4005
Practice Address - Fax:309-691-6144
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036172112208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program