Healthcare Provider Details

I. General information

NPI: 1720086572
Provider Name (Legal Business Name): HOUSHANG FARAHVAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

2222 W DIVISION ST SUITE 235
CHICAGO IL
60622-2717
US

IV. Provider business mailing address

PO BOX 7418
VILLA PARK IL
60181-7418
US

V. Phone/Fax

Practice location:
  • Phone: 773-486-7200
  • Fax: 773-486-7667
Mailing address:
  • Phone: 773-486-7200
  • Fax: 773-486-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036-053620
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: