Provider Demographics
NPI:1174546048
Name:ABTAHI, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:ABTAHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-7190
Mailing Address - Country:US
Mailing Address - Phone:847-375-8889
Mailing Address - Fax:847-375-0396
Practice Address - Street 1:1635 N ARLINGTON HEIGHTS RD STE 203
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3960
Practice Address - Country:US
Practice Address - Phone:847-375-0888
Practice Address - Fax:847-375-0396
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
364194294OtherTAX ID
IL036077353Medicaid
364194294OtherTAX ID