Basic Information
| Provider Information | |||||||||
| NPI: | 1679733620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHAFOURIAN | ||||||||
| FirstName: | KAMBIZ | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 19-100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126643278 | ||||||||
| FaxNumber: | 3126955774 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 19-100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126643278 | ||||||||
| FaxNumber: | 3126955774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2008 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036138882 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | 036138882 | IL | Y |
No ID Information.