Provider Demographics
NPI:1568690899
Name:AUDISHO, SARGON
Entity Type:Individual
Prefix:DR
First Name:SARGON
Middle Name:
Last Name:AUDISHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 E HIGGINS RD
Mailing Address - Street 2:SUITE 113A
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4799
Mailing Address - Country:US
Mailing Address - Phone:224-653-9000
Mailing Address - Fax:
Practice Address - Street 1:4143 N CLAREMONT AVE
Practice Address - Street 2:APT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-2919
Practice Address - Country:US
Practice Address - Phone:312-218-1204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361322412083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine