Provider Demographics
NPI:1487630364
Name:LATALL, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:LATALL
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 1:2073 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4003
Mailing Address - Country:US
Mailing Address - Phone:773-665-4016
Mailing Address - Fax:773-360-6200
Practice Address - Street 1:2073 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4003
Practice Address - Country:US
Practice Address - Phone:773-665-4016
Practice Address - Fax:773-360-6200
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084430207K00000X
IL036-084430207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084430 / 02Medicaid
IL01621679OtherBCBS OF IL
ILF 90691Medicare UPIN
IL036084430 / 02Medicaid