Healthcare Provider Details

I. General information

NPI: 1588854848
Provider Name (Legal Business Name): KONSTANTINS KOCIASVILI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 W LAKE AVE STE 307
GLENVIEW IL
60026-5803
US

IV. Provider business mailing address

333 W DUNDEE RD
BUFFALO GROVE IL
60089-3545
US

V. Phone/Fax

Practice location:
  • Phone: 847-626-8722
  • Fax: 847-316-9502
Mailing address:
  • Phone: 847-243-0355
  • Fax: 847-243-0356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036135325
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: