Provider Demographics
NPI:1396815825
Name:PHATAK, NAYANA UDAY (MD)
Entity type:Individual
Prefix:MRS
First Name:NAYANA
Middle Name:UDAY
Last Name:PHATAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 S. EUCLID AVENUE
Mailing Address - Street 2:UNIT #3
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-484-5462
Mailing Address - Fax:
Practice Address - Street 1:2024 WEST. 79TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620
Practice Address - Country:US
Practice Address - Phone:773-859-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060828Medicaid
IL5700263OtherBLUE CROSS AND BLUE SHIEL
IL036.060820Medicaid