Provider Demographics
NPI:1104933191
Name:KHOSHABA, AUDISHO BRIMO (MD)
Entity type:Individual
Prefix:DR
First Name:AUDISHO
Middle Name:BRIMO
Last Name:KHOSHABA
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 1:2653 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4017
Mailing Address - Country:US
Mailing Address - Phone:773-728-9399
Mailing Address - Fax:773-728-4162
Practice Address - Street 1:2653 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4017
Practice Address - Country:US
Practice Address - Phone:773-728-9399
Practice Address - Fax:773-728-4162
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE48000Medicare UPIN
IL928430Medicare PIN