Individual
PUSHPA K MAMTANI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
5666 E STATE ST, ROCKFORD, IL 61108-2425
(815) 226-2000
Mailing address
5666 E STATE ST, ROCKFORD, IL 61108-2425
(815) 226-2000
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
36 064091
IL
208000000X
Pediatrics Physician
4301503653
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01932040
BCBS
IL
05
—
036064091
—
IL
Enumeration date
12/05/2005
Last updated
03/05/2025
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