Healthcare Provider Details

I. General information

NPI: 1366083032
Provider Name (Legal Business Name): RAMIN GHAZIZADEH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 MAIN ST
PARK FOREST IL
60466-2097
US

IV. Provider business mailing address

231 MAIN ST
PARK FOREST IL
60466-2097
US

V. Phone/Fax

Practice location:
  • Phone: 708-748-3338
  • Fax: 708-748-4332
Mailing address:
  • Phone: 708-748-3338
  • Fax: 708-748-4332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAMIN GHAZIZADEH
Title or Position: OWNER/CEO
Credential: DPM
Phone: 312-330-4574