Healthcare Provider Details

I. General information

NPI: 1053397851
Provider Name (Legal Business Name): JOHN J CUDECKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S WABASH AVE SUITE 106
CHICAGO IL
60616-2955
US

IV. Provider business mailing address

2850 S WABASH AVE SUITE 106
CHICAGO IL
60616-2955
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-4400
  • Fax: 312-842-4595
Mailing address:
  • Phone: 312-842-4400
  • Fax: 312-842-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036080214
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: