Provider Demographics
NPI:1942611694
Name:KANSAL, JAGAN (MD)
Entity Type:Individual
Prefix:
First Name:JAGAN
Middle Name:
Last Name:KANSAL
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 1:20706 CARDINAL CT
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3106
Mailing Address - Country:US
Mailing Address - Phone:312-620-1803
Mailing Address - Fax:
Practice Address - Street 1:1030 N CLARK ST STE 310
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-5413
Practice Address - Country:US
Practice Address - Phone:312-620-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70572208800000X
IL036-153180208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1942611694Medicaid