Healthcare Provider Details

I. General information

NPI: 1124314349
Provider Name (Legal Business Name): GAURANG GUJARATHI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 W COURT ST
KANKAKEE IL
60901
US

IV. Provider business mailing address

1000 REMINGTON BLVD STE 100
BOLINGBROOK IL
60440-4707
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-3200
  • Fax: 815-936-3203
Mailing address:
  • Phone: 630-914-2898
  • Fax: 630-914-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036133707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: