Healthcare Provider Details

I. General information

NPI: 1669176632
Provider Name (Legal Business Name): LOTANNA NWANDU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 12/27/2025
Certification Date: 12/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26117 S COUNTYFAIR DR
MONEE IL
60449-8783
US

IV. Provider business mailing address

26117 S COUNTYFAIR DR
MONEE IL
60449-8783
US

V. Phone/Fax

Practice location:
  • Phone: 708-269-3628
  • Fax:
Mailing address:
  • Phone: 708-269-3628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301515772
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01098646A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: