Healthcare Provider Details

I. General information

NPI: 1043594872
Provider Name (Legal Business Name): KRUPA ANDALKAR P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

2400 N LAKEVIEW AVE APT 1011
CHICAGO IL
60614-2736
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-2123
  • Fax:
Mailing address:
  • Phone: 510-468-5865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085004088
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: