Healthcare Provider Details

I. General information

NPI: 1689904500
Provider Name (Legal Business Name): JASMINE WANG CHAO, D.O., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 WAUKEGAN RD SUITE 202
GLENVIEW IL
60025-3070
US

IV. Provider business mailing address

PO BOX 1666
SKOKIE IL
60076-8666
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-8588
  • Fax: 847-657-8778
Mailing address:
  • Phone: 847-657-8588
  • Fax: 847-657-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number036107878
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036107878
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036107878
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036107878
License Number StateIL

VIII. Authorized Official

Name: MARK CHAO
Title or Position: CORP. SECRETARY
Credential: PH.D.
Phone: 847-657-8588