Healthcare Provider Details

I. General information

NPI: 1699068767
Provider Name (Legal Business Name): ZIYA BAGHMANLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SPRING STREET
RED BUD IL
62278
US

IV. Provider business mailing address

911 FORBES DR
WATERLOO IL
62298-3173
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-3831
  • Fax: 618-282-5476
Mailing address:
  • Phone: 734-709-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.142899
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: