Provider Demographics
NPI:1760898936
Name:FATIMA, NISHAT (MD)
Entity Type:Individual
Prefix:
First Name:NISHAT
Middle Name:
Last Name:FATIMA
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-7884
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:262-948-5735
Practice Address - Street 1:1775 BALLARD RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1005
Practice Address - Country:US
Practice Address - Phone:847-318-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.142329207RE0101X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.142329OtherILLINOIS PHYSICIAN LICENSE
IL036142329Medicaid