SUSIANI INTAN MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****56

License Status

NOT RENEWED

Business

Title

First Name

SUSIANI

Last Name

INTAN

Business Name

SUSIANI INTAN MD

Original Issue Date

07/28/2016

Effective Date

07/28/2016

Expiration Date

07/31/2017

City

CHICAGO

State

Zip

60612

County

COOK

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/01/2017