Provider Demographics
NPI:1649274119
Name:MADHAV, GOPAL (MD)
Entity type:Individual
Prefix:DR
First Name:GOPAL
Middle Name:
Last Name:MADHAV
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 1:3900 W 95TH ST
Mailing Address - Street 2:STE 6
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1901
Mailing Address - Country:US
Mailing Address - Phone:708-423-7734
Mailing Address - Fax:708-423-3282
Practice Address - Street 1:3900 W 95TH ST
Practice Address - Street 2:STE 6
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1901
Practice Address - Country:US
Practice Address - Phone:708-423-7734
Practice Address - Fax:708-423-3282
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-12
Last Update Date:2021-12-17
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
IL036-058991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058991Medicaid
IL672480Medicare ID - Type UnspecifiedMEDICARE NUMBER
ILC43503Medicare UPIN