Provider Demographics
NPI:1518112267
Name:TATKA, KEITH D (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:TATKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2701
Mailing Address - Country:US
Mailing Address - Phone:708-229-5600
Mailing Address - Fax:
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2701
Practice Address - Country:US
Practice Address - Phone:708-229-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124197207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine