Provider Demographics
NPI:1477655926
Name:KHVAT, ELLA (MD)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:KHVAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ACACIA DR
Mailing Address - Street 2:UNIT 705
Mailing Address - City:INDIANHEAD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4487
Mailing Address - Country:US
Mailing Address - Phone:708-246-6021
Mailing Address - Fax:708-246-6073
Practice Address - Street 1:1401 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1858
Practice Address - Country:US
Practice Address - Phone:773-522-2010
Practice Address - Fax:773-522-1177
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL733880Medicare ID - Type Unspecified
ILC46167Medicare UPIN