Healthcare Provider Details

I. General information

NPI: 1962078923
Provider Name (Legal Business Name): GAJENDRA MAHARJAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 W FULTON ST
CHICAGO IL
60612-2345
US

IV. Provider business mailing address

2003 W FULTON ST
CHICAGO IL
60612-2345
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-2223
  • Fax: 312-243-2227
Mailing address:
  • Phone: 312-243-2223
  • Fax: 312-243-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: