Healthcare Provider Details

I. General information

NPI: 1770777658
Provider Name (Legal Business Name): SANJEEB KHATUA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16519 S RTE 59
PLAINFIELD IL
60586-2606
US

IV. Provider business mailing address

16519 S RTE 59
PLAINFIELD IL
60586-2606
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-5020
  • Fax: 630-646-5025
Mailing address:
  • Phone: 630-646-5020
  • Fax: 630-646-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036123917
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier17707776582
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier9933040
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: