Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 19-16542 | IL |
NPI | 1205808854 |
---|---|
Provider Name | Dr. Reza Mostofi |
First Address | Chicago, IL 60659-3450 |
Second Address | Chicago, IL 60659-3450 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2006 |
Last Update Date | 08/07/2007 |