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General NPI Number Information
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NPI Number | 1225621535
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Entity Type | Individual
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Provider Name | TATYANA K MOATON MD
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Gender | Female
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Dates
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Enumeration Date | 02/17/2021
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Last Update Date | 02/17/2021
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Provider Practice Location Address
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Address Line | 6804 S PERRY AVE APT 1A
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City | CHICAGO
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State | IL
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Zip | 60621-3756
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Country | US
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Telephone | 773-974-6003
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 408391
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City | CHICAGO
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State | IL
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Zip | 60640-0010
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Country | US
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Telephone | 773-817-9727
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036-112086
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License Number State | IL
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