Provider Demographics
NPI:1376527168
Name:MAMTANI, PUSHPA K (MD)
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:K
Last Name:MAMTANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PUSHPA
Other - Middle Name:G
Other - Last Name:BALASUBRAMANIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1614 E NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-3681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1614 E NORRIS DR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-3681
Practice Address - Country:US
Practice Address - Phone:815-433-1010
Practice Address - Fax:815-433-0067
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36 064091208000000X
MI4301503653208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064091Medicaid
IL01932040OtherBCBS
E01844Medicare UPIN
E01844Medicare UPIN