Provider Demographics
NPI:1982604377
Name:CHAUDHRY, DEWAT R (MD)
Entity Type:Individual
Prefix:DR
First Name:DEWAT
Middle Name:R
Last Name:CHAUDHRY
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 1:616 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6158
Mailing Address - Country:US
Mailing Address - Phone:309-764-2994
Mailing Address - Fax:309-764-2996
Practice Address - Street 1:616 35TH AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6158
Practice Address - Country:US
Practice Address - Phone:309-764-2994
Practice Address - Fax:309-764-2996
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0504842084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC37635Medicare UPIN