Healthcare Provider Details

I. General information

NPI: 1174821805
Provider Name (Legal Business Name): TANWA A DAWODU NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

13932 S TRACY AVE
RIVERDALE IL
60827-1920
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax:
Mailing address:
  • Phone: 708-841-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.008502
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: