Healthcare Provider Details

I. General information

NPI: 1659700318
Provider Name (Legal Business Name): TANVIR MUSHTAQ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 55TH ST
CHICAGO IL
60615-4906
US

IV. Provider business mailing address

400 N HIGHLAND AVE
AURORA IL
60506-3814
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-2193
  • Fax:
Mailing address:
  • Phone: 630-892-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number336094606
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036133420
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036133420
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: