Healthcare Provider Details

I. General information

NPI: 1487768552
Provider Name (Legal Business Name): KENJI OYASU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 N SHERIDAN RD DEPT OF
WAUKEGAN IL
60085
US

IV. Provider business mailing address

1324 N SHERIDAN RD DEPT OF
WAUKEGAN IL
60085-2161
US

V. Phone/Fax

Practice location:
  • Phone: 847-360-3000
  • Fax:
Mailing address:
  • Phone: 847-360-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberXO9045027
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number036092087
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01066275A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: