Provider Demographics
NPI:1871706523
Name:NEDUMGOTTIL, KOCHUTHRESIA MATHAI (MD)
Entity type:Individual
Prefix:DR
First Name:KOCHUTHRESIA
Middle Name:MATHAI
Last Name:NEDUMGOTTIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 79TH STREET
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2407
Mailing Address - Country:US
Mailing Address - Phone:630-920-1569
Mailing Address - Fax:630-310-8583
Practice Address - Street 1:1901 W. HARRISON ST.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-864-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG76248Medicare UPIN