Provider Demographics
NPI:1245295468
Name:OGALE, MANISHA J (MD)
Entity type:Individual
Prefix:
First Name:MANISHA
Middle Name:J
Last Name:OGALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANISHA
Other - Middle Name:L
Other - Last Name:PRAKASHKAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15900 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-4006
Mailing Address - Country:US
Mailing Address - Phone:708-633-4292
Mailing Address - Fax:
Practice Address - Street 1:45 W 111TH STREET
Practice Address - Street 2:ROSELAND COMMUNITY HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:773-995-3000
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110259Medicaid
ILK26397Medicare ID - Type Unspecified
IL036110259Medicaid