Provider Demographics
NPI:1538125794
Name:NATHANI, DEEPAK (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:
Last Name:NATHANI
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 1:1311 MEMORIAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1495
Mailing Address - Country:US
Mailing Address - Phone:815-539-3405
Mailing Address - Fax:
Practice Address - Street 1:1311 MEMORIAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1495
Practice Address - Country:US
Practice Address - Phone:815-539-3405
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D16229Medicare UPIN
759810Medicare ID - Type Unspecified