Healthcare Provider Details

I. General information

NPI: 1891249793
Provider Name (Legal Business Name): TARANNUM MUJTABA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 MONTGOMERY ROAD
NAPERVILLE IL
60564
US

IV. Provider business mailing address

2000 OGDEN AVE
AURORA IL
60504-7222
US

V. Phone/Fax

Practice location:
  • Phone: 630-236-8300
  • Fax:
Mailing address:
  • Phone: 630-566-2233
  • Fax: 630-566-3429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036.152572
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036152572
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: