Provider Demographics
NPI:1740509579
Name:GHOSH, DEBASREE (MD)
Entity type:Individual
Prefix:DR
First Name:DEBASREE
Middle Name:
Last Name:GHOSH
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 1:6374 N LINCOLN AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1219
Mailing Address - Country:US
Mailing Address - Phone:773-509-0023
Mailing Address - Fax:773-509-1839
Practice Address - Street 1:6374 N LINCOLN AVE STE 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1219
Practice Address - Country:US
Practice Address - Phone:773-509-0023
Practice Address - Fax:773-509-1839
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.124726208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics