Healthcare Provider Details

I. General information

NPI: 1811053978
Provider Name (Legal Business Name): KALYAN BHOGILAL SANDESARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N WESTERN AVE
CHICAGO IL
60622-3565
US

IV. Provider business mailing address

2410 HALINA DR E
GLENVIEW IL
60026-1196
US

V. Phone/Fax

Practice location:
  • Phone: 773-342-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036065899
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: