Provider Demographics
NPI:1538119268
Name:KUSHNER, MARLA (DO)
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:
Last Name:KUSHNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MARLA
Other - Middle Name:
Other - Last Name:KUSHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 14730
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8523
Mailing Address - Country:US
Mailing Address - Phone:773-244-9600
Mailing Address - Fax:833-262-4857
Practice Address - Street 1:2437 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2060
Practice Address - Country:US
Practice Address - Phone:773-244-9600
Practice Address - Fax:773-248-2348
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03675717207Q00000X
IL036075717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075717Medicaid
IL036075717Medicaid