Provider Demographics
NPI:1972564524
Name:BASTANI, AHMAD (MD)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:BASTANI
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 1:6033 N SHERIDAN RD
Mailing Address - Street 2:SUITE S 8
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660
Mailing Address - Country:US
Mailing Address - Phone:773-506-9600
Mailing Address - Fax:773-506-9655
Practice Address - Street 1:6033 N SHERIDAN RD
Practice Address - Street 2:SUITE S 8
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:773-506-9600
Practice Address - Fax:773-506-9655
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4476749OtherAETNA
IL1606175OtherBLUE CROSS BLUE SHIELD
IL036082214Medicaid
IL4476749OtherAETNA
IL952062Medicare ID - Type Unspecified