Provider Demographics
NPI:1285623785
Name:PATRA, KOUSIKI (MD)
Entity type:Individual
Prefix:DR
First Name:KOUSIKI
Middle Name:
Last Name:PATRA
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 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:MURDOCK 622
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-6640
Mailing Address - Fax:312-942-4370
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:MURDOCK 622
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-6640
Practice Address - Fax:312-942-4370
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077993208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2317193Medicaid
I01482Medicare UPIN
OHPA7325271Medicare ID - Type Unspecified