1255412193 NPI number — DR. DARIUSH SAM TAKHTEHCHIAN M.D.

Table of content: DR. DARIUSH SAM TAKHTEHCHIAN M.D. (NPI 1255412193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255412193 NPI number — DR. DARIUSH SAM TAKHTEHCHIAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAKHTEHCHIAN
Provider First Name:
DARIUSH
Provider Middle Name:
SAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255412193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 S PROSPECT AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60126-5643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-782-0190
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5TH ROOSEVELT ROAD
Provider Second Line Business Practice Location Address:
EDWARD HINES, JR HOSPITAL
Provider Business Practice Location Address City Name:
HINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-202-8387
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  036-106592 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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