Basic Information
| Provider Information | |||||||||
| NPI: | 1437261963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAG | ||||||||
| FirstName: | PRATIP | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 S HENNEPIN AVE | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610213083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152887711 | ||||||||
| FaxNumber: | 8152858902 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 NORTH CT | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610211224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855437 | ||||||||
| FaxNumber: | 8152858928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M4388 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036-133213 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036133213 | 05 | IL | MEDICAID |