Healthcare Provider Details

I. General information

NPI: 1033591037
Provider Name (Legal Business Name): KUNAL BAKSHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date: 02/17/2016
Reactivation Date: 05/04/2016

III. Provider practice location address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

IV. Provider business mailing address

1318 GRANROCK CRES
MISSISSAUGA ONTARIO
L5V 0E1
CA

V. Phone/Fax

Practice location:
  • Phone: 773-388-1800
  • Fax:
Mailing address:
  • Phone: 647-701-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301107721
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.157847
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: