Provider Demographics
NPI:1679661797
Name:KAPOOR, MUDRA J (MD)
Entity Type:Individual
Prefix:DR
First Name:MUDRA
Middle Name:J
Last Name:KAPOOR
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 1:26525 N RIVERWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:METTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:60045-3440
Mailing Address - Country:US
Mailing Address - Phone:847-937-5924
Mailing Address - Fax:
Practice Address - Street 1:26525 N RIVERWOODS BLVD
Practice Address - Street 2:
Practice Address - City:METTAWA
Practice Address - State:IL
Practice Address - Zip Code:60045-3440
Practice Address - Country:US
Practice Address - Phone:847-937-5924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2687329Medicaid
OH2687329Medicaid
OHI47042Medicare PIN
OH4196658Medicare PIN