Provider Demographics
NPI:1457443111
Name:SUBOTA, ANATOLY (DC)
Entity Type:Individual
Prefix:
First Name:ANATOLY
Middle Name:
Last Name:SUBOTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3848 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3122
Mailing Address - Country:US
Mailing Address - Phone:773-539-6844
Mailing Address - Fax:
Practice Address - Street 1:3848 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3122
Practice Address - Country:US
Practice Address - Phone:773-539-6844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001682203OtherBC/BS
T36392Medicare UPIN
IL0001682203OtherBC/BS