Provider Demographics
NPI:1407816689
Name:SROUBEK, OTAKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OTAKAR
Middle Name:
Last Name:SROUBEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-774-5020
Mailing Address - Fax:773-774-4967
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-774-5020
Practice Address - Fax:773-774-4967
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071676207RC0000X, 174400000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071676Medicaid
IL678401Medicare ID - Type Unspecified
IL036071676Medicaid