Provider Demographics
NPI:1114037413
Name:BHAKTA, NANDANA C (MD)
Entity Type:Individual
Prefix:DR
First Name:NANDANA
Middle Name:C
Last Name:BHAKTA
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 1:6283 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2505
Mailing Address - Country:US
Mailing Address - Phone:773-585-3131
Mailing Address - Fax:773-585-4565
Practice Address - Street 1:6283 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2505
Practice Address - Country:US
Practice Address - Phone:773-585-3131
Practice Address - Fax:773-585-4565
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36060410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208342OtherGROUP MEDICARE PTAN
ILD14632Medicare UPIN
IL036060410Medicaid