Provider Demographics
NPI:1194955138
Name:KHODADAD, MANUCHER (MD MSE (SURG))
Entity type:Individual
Prefix:DR
First Name:MANUCHER
Middle Name:
Last Name:KHODADAD
Suffix:
Gender:M
Credentials:MD MSE (SURG)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 SHERIDAN RD.
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093
Mailing Address - Country:US
Mailing Address - Phone:847-446-6827
Mailing Address - Fax:847-446-6829
Practice Address - Street 1:627 SHERIDAN RD.
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093
Practice Address - Country:US
Practice Address - Phone:847-446-6827
Practice Address - Fax:847-446-6829
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-040283208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41151Medicare UPIN