Healthcare Provider Details

I. General information

NPI: 1144610080
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS OF ILLINOIS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 ESPLANADE DRIVE SUITE B
ALGONQUIN IL
60102
US

IV. Provider business mailing address

2430 ESPLANADE DRIVE SUITE B
ALGONQUIN IL
60102
US

V. Phone/Fax

Practice location:
  • Phone: 212-627-6515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: VIKRAM KHANNA
Title or Position: PRESIDENT
Credential:
Phone: 847-528-1177