Basic Information
| Provider Information | |||||||||
| NPI: | 1942373931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NANDRA | ||||||||
| FirstName: | MUKHTAR | ||||||||
| MiddleName: | SINGH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E SOUTH ST | ||||||||
| Address2: | UNIT F | ||||||||
| City: | PLANO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605451417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305527166 | ||||||||
| FaxNumber: | 6305527168 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 E SOUTH ST | ||||||||
| Address2: | UNIT F | ||||||||
| City: | PLANO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605451417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305527166 | ||||||||
| FaxNumber: | 6305527168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-083629 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4377 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 31673 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-083629 | 05 | IL | MEDICAID |