Provider Demographics
NPI:1720523731
Name:AMAR L DAVE
Entity Type:Organization
Organization Name:AMAR L DAVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMAR
Authorized Official - Middle Name:LAL
Authorized Official - Last Name:DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-434-2115
Mailing Address - Street 1:1209 STARFIRE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1614
Mailing Address - Country:US
Mailing Address - Phone:815-434-2115
Mailing Address - Fax:
Practice Address - Street 1:1209 STARFIRE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1614
Practice Address - Country:US
Practice Address - Phone:815-434-2115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057338208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057338Medicaid