Provider Demographics
NPI:1518937937
Name:CANDIDO, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CANDIDO
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 1:509 RIDGEMOOR DR
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5358
Mailing Address - Country:US
Mailing Address - Phone:847-615-2200
Mailing Address - Fax:847-615-2858
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:SUITE 4815
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7934
Practice Address - Fax:773-296-5088
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36075131208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075131Medicaid
ILK12558Medicare ID - Type Unspecified
ILK12559Medicare ID - Type Unspecified
IL036075131Medicaid