Healthcare Provider Details

I. General information

NPI: 1780606566
Provider Name (Legal Business Name): DATTA SAMBARE M D S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 S WEBER RD UNIT G
BOLINGBROOK IL
60490-5472
US

IV. Provider business mailing address

PO BOX 215
WESTMONT IL
60559-0215
US

V. Phone/Fax

Practice location:
  • Phone: 630-378-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DATTA SAMBARE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 630-378-2000