Provider Demographics
NPI:1003878703
Name:KAUSHAL, NEETA B (MD)
Entity Type:Individual
Prefix:DR
First Name:NEETA
Middle Name:B
Last Name:KAUSHAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 N WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6296
Mailing Address - Country:US
Mailing Address - Phone:618-242-5437
Mailing Address - Fax:
Practice Address - Street 1:4107 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6296
Practice Address - Country:US
Practice Address - Phone:618-242-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094868Medicaid
IL207988OtherGROUP
ILCE9335OtherRR GROUP NUMBER
ILP00345211OtherRR MEDICARE NUMBER
ILP00345211OtherRR MEDICARE NUMBER