Basic Information
| Provider Information | |||||||||
| NPI: | 1811929474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GITTLER | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606225646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
| FaxNumber: | 3126666228 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 N CALIFORNIA AVE | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606257014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
| FaxNumber: | 7732936846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00039065 | WA | N | Other Service Providers | Specialist | 207Q00000X | 01074721A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036107772 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-107772 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036107772 | 05 | IL | MEDICAID | 11146653 | 01 | IL | CAQH | OTHER |