Healthcare Provider Details

I. General information

NPI: 1912167073
Provider Name (Legal Business Name): TAKEYOSHI OTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
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 SUITE 300
BURR RIDGE IL
60527-5919
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 TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036133284
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: