Provider Demographics
NPI:1639246861
Name:MAYO-FORD, CHANDA (MD)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:
Last Name:MAYO-FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-6078
Mailing Address - Country:US
Mailing Address - Phone:630-909-7000
Mailing Address - Fax:630-909-7001
Practice Address - Street 1:3 ERIE CT
Practice Address - Street 2:5N
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2519
Practice Address - Country:US
Practice Address - Phone:708-987-0064
Practice Address - Fax:708-763-1306
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI37912Medicare UPIN
ILK19846Medicare ID - Type Unspecified
ILK19847Medicare ID - Type Unspecified