Healthcare Provider Details

I. General information

NPI: 1710515234
Provider Name (Legal Business Name): MICHAEL ESHA NISSAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N DEARBORN ST
CHICAGO IL
60654-3846
US

IV. Provider business mailing address

6715 N MINNEHAHA AVE
LINCOLNWOOD IL
60712-3108
US

V. Phone/Fax

Practice location:
  • Phone: 312-469-0123
  • Fax:
Mailing address:
  • Phone: 773-899-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036176973
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: