Basic Information
| Provider Information | |||||||||
| NPI: | 1003143231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENSHIWAT | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | LUMA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10445 S KILDARE AVE | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604534805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083694050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4440 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086848000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301095446 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036.147464 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.