Provider Demographics
NPI:1982641718
Name:DALAL, NEHA (PA)
Entity Type:Individual
Prefix:
First Name:NEHA
Middle Name:
Last Name:DALAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W LAKE COOK RD
Mailing Address - Street 2:STE 120
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2089
Mailing Address - Country:US
Mailing Address - Phone:847-808-8884
Mailing Address - Fax:847-808-8890
Practice Address - Street 1:600 W LAKE COOK RD
Practice Address - Street 2:STE 120
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2089
Practice Address - Country:US
Practice Address - Phone:847-808-8884
Practice Address - Fax:847-808-8890
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001634363A00000X
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
039838OtherWELL MARK BCBS OF IA
I16288Medicare ID - Type Unspecified
Q54651Medicare UPIN