Provider Demographics
NPI:1215121066
Name:MORADIA, JADAV M (MD)
Entity type:Individual
Prefix:
First Name:JADAV
Middle Name:M
Last Name:MORADIA
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 1:1600 DEMPSTER ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1109
Mailing Address - Country:US
Mailing Address - Phone:847-803-9393
Mailing Address - Fax:847-803-1358
Practice Address - Street 1:1600 DEMPSTER ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1109
Practice Address - Country:US
Practice Address - Phone:847-803-9393
Practice Address - Fax:847-803-1358
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01627439OtherB.C.,B.S.
IL036048772Medicaid
IL364423658OtherCOMMERCIAL
IL364423658OtherCOMMERCIAL
IL036048772Medicaid