Provider Demographics
NPI:1457487597
Name:IDUNA, LELA (MD)
Entity Type:Individual
Prefix:DR
First Name:LELA
Middle Name:
Last Name:IDUNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SAMINA
Other - Middle Name:
Other - Last Name:SHAHABUDDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14311 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7368
Mailing Address - Country:US
Mailing Address - Phone:510-666-5062
Mailing Address - Fax:
Practice Address - Street 1:14311 PERKINS RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7368
Practice Address - Country:US
Practice Address - Phone:510-666-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134053207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC37626058Medicare PIN
MIP00620594Medicare PIN