Healthcare Provider Details

I. General information

NPI: 1215023916
Provider Name (Legal Business Name): SHAISTA Y KAMAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7464 N CLARK ST
CHICAGO IL
60626-1620
US

IV. Provider business mailing address

7464 N CLARK ST
CHICAGO IL
60626-1620
US

V. Phone/Fax

Practice location:
  • Phone: 773-381-8700
  • Fax: 773-381-8701
Mailing address:
  • Phone: 773-381-8700
  • Fax: 773-381-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036116435
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: