Provider Demographics
NPI:1811929474
Name:GITTLER, MANDY L (MD)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:L
Last Name:GITTLER
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 1:1701 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5646
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:312-666-6228
Practice Address - Street 1:5215 N CALIFORNIA AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:773-293-6846
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039065174400000X
IN01074721A207Q00000X
IL036107772207Q00000X
IL036-107772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107772Medicaid
IL11146653OtherCAQH
IL036107772Medicaid