Healthcare Provider Details

I. General information

NPI: 1649384256
Provider Name (Legal Business Name): AZITA ARDAKANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 WILLOW SPRINGS RD STE 120
LA GRANGE HIGHLANDS IL
60525-6540
US

IV. Provider business mailing address

5201 WILLOW SPRINGS RD 120
LA GRANGE HIGHLANDS IL
60525-6537
US

V. Phone/Fax

Practice location:
  • Phone: 708-245-6097
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-089177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: