Healthcare Provider Details

I. General information

NPI: 1871116699
Provider Name (Legal Business Name): GAUTAM DUA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 GREEN BAY RD
NORTH CHICAGO IL
60064-3037
US

IV. Provider business mailing address

1615 ORANGE AVE APT 217
REDLANDS CA
92373-4361
US

V. Phone/Fax

Practice location:
  • Phone: 847-578-3000
  • Fax:
Mailing address:
  • Phone: 714-392-9821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number114463
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: