Provider Demographics
NPI:1962498394
Name:TOMITA, TADANORI (MD)
Entity Type:Individual
Prefix:
First Name:TADANORI
Middle Name:
Last Name:TOMITA
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 1:35422 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-0001
Mailing Address - Country:US
Mailing Address - Phone:773-880-4000
Mailing Address - Fax:
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-880-4000
Practice Address - Fax:773-281-1576
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061591207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0563684Medicaid
WA8023632Medicaid
IL036061591Medicaid
IL1627123OtherBCBS PROVIDER ID
IL7618592OtherGHI PROVIDER ID
IL1627123OtherBCBS PROVIDER ID
WA8023632Medicaid