Healthcare Provider Details

I. General information

NPI: 1508516865
Provider Name (Legal Business Name): NATHAN TAN NAVARRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 08/27/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4822 S COTTAGE GROVE AVE STE 4-200
CHICAGO IL
60615
US

IV. Provider business mailing address

4822 S COTTAGE GROVE AVE STE 4-200
CHICAGO IL
60615
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-3627
  • Fax: 312-921-1051
Mailing address:
  • Phone: 312-926-3627
  • Fax: 312-921-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.080694
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036172742
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: