Healthcare Provider Details

I. General information

NPI: 1609678804
Provider Name (Legal Business Name): DUA KANWAL IQBAL KALOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 S RIDGELAND AVE
PALOS HEIGHTS IL
60463-2390
US

IV. Provider business mailing address

54 W 19TH ST
LOMBARD IL
60148-4971
US

V. Phone/Fax

Practice location:
  • Phone: 708-429-3700
  • Fax:
Mailing address:
  • Phone: 630-827-2977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85.011629
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: