Provider Demographics
NPI:1649945346
Name:KAUL, DIKSHA
Entity type:Individual
Prefix:MS
First Name:DIKSHA
Middle Name:
Last Name:KAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:APT 524, THE POINT AT 180
Mailing Address - Street 2:180 EASTERN AVENUE
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 S KEDZIE AVE STE D
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-6307
Practice Address - Country:US
Practice Address - Phone:708-684-6867
Practice Address - Fax:708-684-6869
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2024-08-16
Deactivation Date:2022-12-19
Deactivation Code:
Reactivation Date:2023-09-12
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.170390207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program