Healthcare Provider Details

I. General information

NPI: 1245295468
Provider Name (Legal Business Name): MANISHA J OGALE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MANISHA L PRAKASHKAR MD

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 111TH STREET ROSELAND COMMUNITY HOSPITAL
CHICAGO IL
60628
US

IV. Provider business mailing address

15900 S CICERO AVE
OAK FOREST IL
60452-4006
US

V. Phone/Fax

Practice location:
  • Phone: 773-995-3000
  • Fax: 630-734-1560
Mailing address:
  • Phone: 708-633-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036110259
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: