Healthcare Provider Details

I. General information

NPI: 1558007237
Provider Name (Legal Business Name): SHAYAN FEYZI GHARAGOZLOU DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17148 HARLEM AVE
TINLEY PARK IL
60477-3331
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 708-429-1200
  • Fax: 708-429-4845
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberU8330
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036-176079
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10080620
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: