Provider Demographics
NPI:1215059977
Name:KISHORE, KAMAL (MD)
Entity type:Individual
Prefix:
First Name:KAMAL
Middle Name:
Last Name:KISHORE
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:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61650-0036
Mailing Address - Country:US
Mailing Address - Phone:815-223-7400
Mailing Address - Fax:
Practice Address - Street 1:3602 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1450
Practice Address - Country:US
Practice Address - Phone:815-223-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-100858207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology