Provider Demographics
NPI:1316636723
Name:MATA-THIMM, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MATA-THIMM
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 1:1950 W POLK ST FL 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-4480
Mailing Address - Fax:520-626-6020
Practice Address - Street 1:1950 W POLK ST FL 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-4480
Practice Address - Fax:234-405-3808
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125084992207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology