Healthcare Provider Details

I. General information

NPI: 1942611694
Provider Name (Legal Business Name): JAGAN K KANSAL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 N CLARK ST STE 310
CHICAGO IL
60610-5413
US

IV. Provider business mailing address

20706 CARDINAL CT
FRANKFORT IL
60423-3106
US

V. Phone/Fax

Practice location:
  • Phone: 312-620-1803
  • Fax:
Mailing address:
  • Phone: 312-620-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-153180
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01097404A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number70572
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: