Healthcare Provider Details

I. General information

NPI: 1851968424
Provider Name (Legal Business Name): SEPIDEH TABARESTANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 710
CHICAGO IL
60612-3863
US

IV. Provider business mailing address

1725 W HARRISON ST STE 710
CHICAGO IL
60612-3863
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-4036
  • Fax:
Mailing address:
  • Phone: 312-942-4036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number036173266
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberAU4176435-T999110981
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: