Provider Demographics
NPI:1659483337
Name:MAGO, TANVI DINESH (OD)
Entity Type:Individual
Prefix:DR
First Name:TANVI
Middle Name:DINESH
Last Name:MAGO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TANVI
Other - Middle Name:DINESH
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:230 E OHIO ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3265
Mailing Address - Country:US
Mailing Address - Phone:917-414-9434
Mailing Address - Fax:
Practice Address - Street 1:230 E OHIO ST
Practice Address - Street 2:STE 120
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3265
Practice Address - Country:US
Practice Address - Phone:917-414-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6844152W00000X
IL9935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046.009935Medicaid
IL046009935Medicaid