Basic Information
| Provider Information | |||||||||
| NPI: | 1780175612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IOFFE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | CHONGSUWAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9977 WOODS DR | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2243642273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9977 WOODS DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2243642273 | ||||||||
| FaxNumber: | 8476638290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2018 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036154445 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.