Healthcare Provider Details

I. General information

NPI: 1245792308
Provider Name (Legal Business Name): TODD MICHAEL GOGLIA CHATLOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

150 HARVESTER DR STE 300
BURR RIDGE IL
60527-5965
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number01096730A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA178208
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number036174745
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036174745
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberA178208
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA178208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: