Provider Demographics
NPI:1245858935
Name:KIDIWALA, MASUM
Entity type:Individual
Prefix:
First Name:MASUM
Middle Name:
Last Name:KIDIWALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8841 MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2531
Mailing Address - Country:US
Mailing Address - Phone:847-899-2544
Mailing Address - Fax:
Practice Address - Street 1:8841 MAJOR AVE
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2531
Practice Address - Country:US
Practice Address - Phone:847-899-2544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041476223163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical