MEDICARE: DR. ITHAAR DERWEESH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	036.176621	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003873720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ITHAAR DERWEESH MD

Provider Business Mailing Address
First Line	:	1620 W HARRISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3801
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 W HARRISON ST STE 970
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3828
Country	:	US
Telephone Number	:	312-563-3447
Fax Number	:	312-563-3721

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	02/16/2026

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