Provider Demographics
NPI:1689802340
Name:KHOSROPOUR, ANDREA MINA (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MINA
Last Name:KHOSROPOUR
Suffix:
Gender:F
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 746721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1541 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1313
Practice Address - Country:US
Practice Address - Phone:773-250-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine