Healthcare Provider Details

I. General information

NPI: 1659543874
Provider Name (Legal Business Name): ASAD QALBANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1400 EMELINE AVE
SANTA CRUZ CA
95060-1976
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 831-454-4170
  • Fax: 831-454-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number036.119633
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC168670
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberTD081067
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: