Healthcare Provider Details

I. General information

NPI: 1215057773
Provider Name (Legal Business Name): KATHLEEN MARISA LASLO M.D., MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W SUPERIOR ST
CHICAGO IL
60622-5646
US

IV. Provider business mailing address

4937 N CHRISTIANA AVE
CHICAGO IL
60625-5003
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-3494
  • Fax: 312-666-6228
Mailing address:
  • Phone: 773-750-1513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036116369
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: