Provider Demographics
NPI:1699977413
Name:DHAMIJA, MANISH KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:MANISH
Middle Name:KUMAR
Last Name:DHAMIJA
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 1:3534 N FREMONT ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1926
Mailing Address - Country:US
Mailing Address - Phone:513-236-7323
Mailing Address - Fax:
Practice Address - Street 1:3000 N HALSTED ST STE 625
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5196
Practice Address - Country:US
Practice Address - Phone:773-281-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36117326207R00000X
NDLT 12568207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17454Medicaid
NDN718361Medicare PIN
NDN718360Medicare PIN