Healthcare Provider Details

I. General information

NPI: 1053809715
Provider Name (Legal Business Name): AJAY KAILAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2018
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 LINDEN AVE
WILMETTE IL
60091-2844
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 847-843-3376
  • Fax: 847-920-9188
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.158642
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: