Provider Demographics
NPI:1538573381
Name:CHOUDHURY, IBTISAM
Entity type:Individual
Prefix:
First Name:IBTISAM
Middle Name:
Last Name:CHOUDHURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 N GREEN BAY RD APT 1608
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 GREEN BAY ROAD
Practice Address - Street 2:
Practice Address - City:NOTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-578-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250642152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry