Healthcare Provider Details

I. General information

NPI: 1083689137
Provider Name (Legal Business Name): MARIA MAGDALENE TSOUKAS M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 3E
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

1847 N DAYTON ST
CHICAGO IL
60614-5002
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-7448
  • Fax: 312-996-1188
Mailing address:
  • Phone: 312-479-8649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036114916
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number223293
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: