Healthcare Provider Details

I. General information

NPI: 1487818175
Provider Name (Legal Business Name): SUNITHA TATA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

3130 N LAKESHORE DR APT #301
CHICAGO IL
60657
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54617
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125054320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: