Healthcare Provider Details

I. General information

NPI: 1699468991
Provider Name (Legal Business Name): NISHITA RAO VATTEM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17800 KEDZIE AVE
HAZEL CREST IL
60429-2029
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 312-609-0300
  • Fax: 773-213-0378
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.180585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: