Provider Demographics
NPI:1447243258
Name:DUGGAL, MANOJ (MD,FACC)
Entity Type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:
Last Name:DUGGAL
Suffix:
Gender:M
Credentials:MD,FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2401
Mailing Address - Country:US
Mailing Address - Phone:708-636-7575
Mailing Address - Fax:708-636-7193
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-636-7575
Practice Address - Fax:708-636-6193
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085016207RC0001X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCI8250OtherPALMETTO GBA GROUP #
IL21622931OtherBCBS GROUP #
IL036085016Medicaid
IL060053840OtherPALMETTO GBA INDIVIDUAL #
ILG39337Medicare UPIN
IL526200Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILL68056Medicare ID - Type UnspecifiedMEDICARE INDIV PROV ID #
IL388180Medicare ID - Type UnspecifiedANOTHER MEDICARE GROUP #
ILL68056Medicare PIN