Healthcare Provider Details

I. General information

NPI: 1558667170
Provider Name (Legal Business Name): MANDANA FAGHANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR ST STE 101
MELROSE PARK IL
60160-4100
US

IV. Provider business mailing address

1008 PLEASANT ST APT# 1A
OAK PARK IL
60302-3059
US

V. Phone/Fax

Practice location:
  • Phone: 708-344-2161
  • Fax:
Mailing address:
  • Phone: 708-567-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125054453
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: