Healthcare Provider Details

I. General information

NPI: 1265560882
Provider Name (Legal Business Name): BALA HOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W POLK ST
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

12615 SUFFIELD DR
PALOS PARK IL
60464-2592
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number036100265
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: