Provider Demographics
NPI:1659827186
Name:MUKHOPADHYAY, DIPANKAR
Entity Type:Individual
Prefix:
First Name:DIPANKAR
Middle Name:
Last Name:MUKHOPADHYAY
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 1:5101 WILLOW SPRINGS RD
Mailing Address - Street 2:FAMILY PRACTICE RESIDENCY
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2600
Mailing Address - Country:US
Mailing Address - Phone:708-245-8900
Mailing Address - Fax:708-245-5615
Practice Address - Street 1:5101 WILLOW SPRINGS RD
Practice Address - Street 2:FAMILY PRACTICE RESIDENCY
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2600
Practice Address - Country:US
Practice Address - Phone:708-245-8900
Practice Address - Fax:708-245-5615
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045296208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics