Provider Demographics
NPI:1760930028
Name:KITAHARA, HIROTO
Entity Type:Individual
Prefix:MR
First Name:HIROTO
Middle Name:
Last Name:KITAHARA
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 1:180 HARVESTER DRIVE, SUITE 110, BURR RIDGE
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:773-702-1150
Mailing Address - Fax:
Practice Address - Street 1:5841 S. MARYLAND AVENUE M/C6040
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147730207RC0000X
IL125069403208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease