Healthcare Provider Details

I. General information

NPI: 1265142129
Provider Name (Legal Business Name): DOWN THERE UROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 12/10/2022
Certification Date: 12/10/2022
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 TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAGAN KANSAL
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 312-620-1803