Healthcare Provider Details

I. General information

NPI: 1346256245
Provider Name (Legal Business Name): KOUROSH DINI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S WABASH AVE APT 4G
CHICAGO IL
60605-2255
US

IV. Provider business mailing address

1020 S WABASH AVE APT 4G
CHICAGO IL
60605-2255
US

V. Phone/Fax

Practice location:
  • Phone: 312-391-3171
  • Fax:
Mailing address:
  • Phone: 312-391-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036107898
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036107898
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: