Provider Demographics
NPI:1073133138
Name:KADAKIA, TOSHA R
Entity Type:Individual
Prefix:
First Name:TOSHA
Middle Name:R
Last Name:KADAKIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-7731
Mailing Address - Country:US
Mailing Address - Phone:630-770-3484
Mailing Address - Fax:
Practice Address - Street 1:1221 HANOVER ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-7731
Practice Address - Country:US
Practice Address - Phone:630-770-3484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-19
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMA062998363A00000X
IL085008008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program