Healthcare Provider Details

I. General information

NPI: 1093764193
Provider Name (Legal Business Name): KAMRAN HEYDARPOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ERIE CT SUITE NUMBER 3200
OAK PARK IL
60302-2566
US

IV. Provider business mailing address

PO BOX 14905
CHICAGO IL
60614-0905
US

V. Phone/Fax

Practice location:
  • Phone: 708-763-8248
  • Fax:
Mailing address:
  • Phone: 708-763-8248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036091055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: