Healthcare Provider Details

I. General information

NPI: 1609443571
Provider Name (Legal Business Name): JONATHAN BAUTISTA TANAWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

1431 N WESTERN AVE STE 406
CHICAGO IL
60622-1774
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-0516
  • Fax: 312-491-5020
Mailing address:
  • Phone: 312-633-5841
  • Fax: 312-491-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.170234
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number036.170234
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: