Provider Demographics
NPI:1811204019
Name:NINAN, BONEY MATTATHETHU (MD)
Entity Type:Individual
Prefix:DR
First Name:BONEY
Middle Name:MATTATHETHU
Last Name:NINAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 W HARRISON ST
Mailing Address - Street 2:APT 3 B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3169
Mailing Address - Country:US
Mailing Address - Phone:630-398-1030
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST
Practice Address - Street 2:MEDICINE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125057406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine