Healthcare Provider Details

I. General information

NPI: 1205496197
Provider Name (Legal Business Name): ALI KHOSHKISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

IV. Provider business mailing address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

V. Phone/Fax

Practice location:
  • Phone: 847-377-8075
  • Fax: 847-984-5685
Mailing address:
  • Phone: 847-377-8075
  • Fax: 847-984-5685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number180503
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125.074229
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: