Provider Demographics
NPI:1972523892
Name:GHODSIZADEH, EBRAHIM (MD)
Entity type:Individual
Prefix:DR
First Name:EBRAHIM
Middle Name:
Last Name:GHODSIZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EBRAHIM
Other - Middle Name:M
Other - Last Name:GHODSIZADEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4438 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3743
Mailing Address - Country:US
Mailing Address - Phone:773-794-2100
Mailing Address - Fax:773-794-2492
Practice Address - Street 1:4438 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3743
Practice Address - Country:US
Practice Address - Phone:773-794-2100
Practice Address - Fax:773-794-2492
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BG4167171OtherDEA
BG4167171OtherDEA
F54283Medicare UPIN
IL536800Medicare ID - Type Unspecified