Healthcare Provider Details

I. General information

NPI: 1639170731
Provider Name (Legal Business Name): JAY K. CHAUHAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 05/19/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 LANDMARK DR
NORMAL IL
61761-3195
US

IV. Provider business mailing address

611 W. PARK ST FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036086823
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number036086823
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036086823
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: