Provider Demographics
NPI:1215979729
Name:SUD, MADHUPA (MD)
Entity type:Individual
Prefix:DR
First Name:MADHUPA
Middle Name:
Last Name:SUD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0306
Mailing Address - Country:US
Mailing Address - Phone:630-325-1177
Mailing Address - Fax:
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:773-995-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD12614Medicare UPIN