Provider Demographics
NPI:1851306575
Name:MACWAN, KAMLESH SAMSON (MD)
Entity Type:Individual
Prefix:MR
First Name:KAMLESH
Middle Name:SAMSON
Last Name:MACWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1186
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61555-1186
Mailing Address - Country:US
Mailing Address - Phone:309-353-4483
Mailing Address - Fax:309-353-7713
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:ST FRANCIS MEDICAL CENTER
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637
Practice Address - Country:US
Practice Address - Phone:309-655-2485
Practice Address - Fax:309-655-2874
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL53948208000000X
IL32482080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL004082OtherHEALTH ALLIANCE
ILIL0105OtherJOHN DEERE
IL03608163702Medicaid
IL7215111OtherBLUE CROSS BLUE SHIELD