Healthcare Provider Details

I. General information

NPI: 1447299672
Provider Name (Legal Business Name): MITA I PATEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1901W HARRISON ST
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6036
  • Fax: 312-864-7004
Mailing address:
  • Phone: 312-864-6036
  • Fax: 312-864-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-076626
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: