Provider Demographics
NPI:1629203534
Name:NANDRA FAMILY PRACTICE, LTD.
Entity Type:Organization
Organization Name:NANDRA FAMILY PRACTICE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUKHTAR
Authorized Official - Middle Name:S
Authorized Official - Last Name:NANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-552-7166
Mailing Address - Street 1:115 E SOUTH ST
Mailing Address - Street 2:UNIT F
Mailing Address - City:PLANO
Mailing Address - State:IL
Mailing Address - Zip Code:60545-1417
Mailing Address - Country:US
Mailing Address - Phone:630-552-7166
Mailing Address - Fax:630-552-7168
Practice Address - Street 1:115 E SOUTH ST
Practice Address - Street 2:UNIT F
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545-1417
Practice Address - Country:US
Practice Address - Phone:630-552-7166
Practice Address - Fax:630-552-7168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083629207Q00000X
IL036-119568207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1639358427OtherNPI
IL036-083629Medicaid
1942373931OtherNPI
618560Medicare PIN