Healthcare Provider Details

I. General information

NPI: 1518937937
Provider Name (Legal Business Name): KENNETH CANDIDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE SUITE 4815
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

509 RIDGEMOOR DR
WILLOWBROOK IL
60527-5358
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7934
  • Fax: 773-296-5088
Mailing address:
  • Phone: 847-615-2200
  • Fax: 847-615-2858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number36075131
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: