Healthcare Provider Details

I. General information

NPI: 1093740490
Provider Name (Legal Business Name): BRIAN CASACLANG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N SHEFFIELD AVE
CHICAGO IL
60614-2215
US

IV. Provider business mailing address

2311 W 22ND ST SUITE 202
OAK BROOK IL
60523-1225
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-0320
  • Fax:
Mailing address:
  • Phone: 630-320-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: