Healthcare Provider Details

I. General information

NPI: 1942373931
Provider Name (Legal Business Name): MUKHTAR SINGH NANDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E SOUTH ST UNIT F
PLANO IL
60545-1417
US

IV. Provider business mailing address

115 E SOUTH ST UNIT F
PLANO IL
60545-1417
US

V. Phone/Fax

Practice location:
  • Phone: 630-552-7166
  • Fax: 630-552-7168
Mailing address:
  • Phone: 630-552-7166
  • Fax: 630-552-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-083629
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4377
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31673
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: