Healthcare Provider Details

I. General information

NPI: 1639993538
Provider Name (Legal Business Name): AIGUL ZHOLDOSHOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 S WOOD ST # 162-A
CHICAGO IL
60612-4300
US

IV. Provider business mailing address

402 S HELENA AVE
MT PROSPECT IL
60056-2854
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6635
  • Fax:
Mailing address:
  • Phone: 832-610-8126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number125.085064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: