Provider Demographics
NPI:1548292832
Name:GADULA, MARIUSZ W (MD)
Entity type:Individual
Prefix:DR
First Name:MARIUSZ
Middle Name:W
Last Name:GADULA
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 1:4609 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4718
Mailing Address - Country:US
Mailing Address - Phone:708-425-0070
Mailing Address - Fax:708-425-0304
Practice Address - Street 1:4609 W 103RD ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4718
Practice Address - Country:US
Practice Address - Phone:708-425-0070
Practice Address - Fax:708-425-0304
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088145207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088145Medicaid
F79240Medicare UPIN
IL343710Medicare ID - Type Unspecified