Provider Demographics
NPI:1871950741
Name:SADRAMELI, MITRA
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:SADRAMELI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S PRAIRIE AVE APT 4901
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3570
Mailing Address - Country:US
Mailing Address - Phone:312-966-6307
Mailing Address - Fax:
Practice Address - Street 1:1201 S PRAIRIE AVE APT 4901
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3570
Practice Address - Country:US
Practice Address - Phone:312-966-6307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-24
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0304341223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.030434OtherSTATE OF ILLINOIS, DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION