Healthcare Provider Details

I. General information

NPI: 1205745262
Provider Name (Legal Business Name): MOHAMAD GOLDUST JOUYBARI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MOHAMAD GOLDUST

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S WOOD ST
CHICAGO IL
60612-7300
US

IV. Provider business mailing address

808 S WOOD ST
CHICAGO IL
60612-7300
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6966
  • Fax:
Mailing address:
  • Phone: 312-996-6966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number113.000100
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: