Provider Demographics
NPI:1508866559
Name:CHAUDHRY, MUKESH (MD)
Entity Type:Individual
Prefix:
First Name:MUKESH
Middle Name:
Last Name:CHAUDHRY
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 1:190 HIGH FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-8245
Mailing Address - Country:US
Mailing Address - Phone:618-549-0300
Mailing Address - Fax:
Practice Address - Street 1:1175 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5333
Practice Address - Country:US
Practice Address - Phone:618-549-0300
Practice Address - Fax:618-549-0600
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-107111Medicaid
ILH70512Medicare UPIN
IL036-107111Medicaid