Healthcare Provider Details

I. General information

NPI: 1801070370
Provider Name (Legal Business Name): JONATHAN BENJAMIN IDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 25
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 25
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-6234
  • Fax: 312-227-9414
Mailing address:
  • Phone: 312-227-6234
  • Fax: 312-227-9414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD.200263
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number35.094270
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number1801070370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: