Provider Demographics
NPI:1568891299
Name:KADIWALA, KUNJAL (PA-C)
Entity Type:Individual
Prefix:
First Name:KUNJAL
Middle Name:
Last Name:KADIWALA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KUNJAL
Other - Middle Name:
Other - Last Name:RAICHURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:660 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1659
Mailing Address - Country:US
Mailing Address - Phone:847-582-2134
Mailing Address - Fax:
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-535-6911
Practice Address - Fax:847-535-7203
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004822363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical