Healthcare Provider Details

I. General information

NPI: 1578103974
Provider Name (Legal Business Name): YURI SERGEYEVICH KUKLOV PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 W HIGGINS RD STE 101
HOFFMAN ESTATES IL
60169-2174
US

IV. Provider business mailing address

1160 WINDBROOKE DR
BUFFALO GROVE IL
60089-2300
US

V. Phone/Fax

Practice location:
  • Phone: 847-750-6877
  • Fax: 708-316-8866
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: