Healthcare Provider Details

I. General information

NPI: 1700100237
Provider Name (Legal Business Name): CARLY B OBOUDIYAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST SUITE 945
CHICAGO IL
60611-2927
US

IV. Provider business mailing address

676 N SAINT CLAIR ST SUITE 945
CHICAGO IL
60611-2927
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7902
  • Fax:
Mailing address:
  • Phone: 312-695-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036135484
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: