Healthcare Provider Details

I. General information

NPI: 1659808483
Provider Name (Legal Business Name): CAROLYN KELLY LAGATTUTA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 N MILWAUKEE AVE
CHICAGO IL
60641-2703
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-6125
  • Fax: 773-736-9629
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.071306
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-151860
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: