Provider Demographics
NPI:1033591037
Name:BAKSHI, KUNAL (MD)
Entity Type:Individual
Prefix:
First Name:KUNAL
Middle Name:
Last Name:BAKSHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 GRANROCK CRES
Mailing Address - Street 2:
Mailing Address - City:MISSISSAUGA
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L5V 0E1
Mailing Address - Country:CA
Mailing Address - Phone:647-701-0473
Mailing Address - Fax:
Practice Address - Street 1:4025 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2010
Practice Address - Country:US
Practice Address - Phone:773-388-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2021-10-21
Deactivation Date:2016-02-17
Deactivation Code:
Reactivation Date:2016-05-04
Provider Licenses
StateLicense IDTaxonomies
MI4301107721207Q00000X
IL036.157847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.157847Medicaid