Provider Demographics
NPI:1568865772
Name:UBAGHARA, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:UBAGHARA
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 1:555 S SCHUYLER AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-5178
Mailing Address - Country:US
Mailing Address - Phone:815-401-6666
Mailing Address - Fax:815-614-3363
Practice Address - Street 1:555 S SCHUYLER AVE STE 235
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-5178
Practice Address - Country:US
Practice Address - Phone:312-405-5670
Practice Address - Fax:219-306-8090
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILU12654362296172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver