Healthcare Provider Details

I. General information

NPI: 1861486722
Provider Name (Legal Business Name): NINA W KHAZEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 OGDEN AVE STE 101
LISLE IL
60532-1673
US

IV. Provider business mailing address

3033 OGDEN AVE STE 101
LISLE IL
60532-1673
US

V. Phone/Fax

Practice location:
  • Phone: 630-717-5700
  • Fax: 630-717-0665
Mailing address:
  • Phone: 630-717-5700
  • Fax: 630-717-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036104073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: