Individual
DR. MAHTAB TASHAKORI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1802 SOUTH MATTIS AVE, CHAMPAIGN, IL 61821
(217) 326-1220
Mailing address
PO BOX 6002, URBANA, IL 61803-6002
(217) 337-4105
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036113377
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
553180
MEDICARE GROUP NUMBER
IL
01
—
834340
MEDICARE GROUP NUMBER
IL
Enumeration date
07/01/2006
Last updated
11/02/2009
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