Provider Demographics
NPI:1366788697
Name:VETERANS SQUARE DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:VETERANS SQUARE DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KODNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-622-8700
Mailing Address - Street 1:4849 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-5100
Mailing Address - Country:US
Mailing Address - Phone:773-622-8700
Mailing Address - Fax:
Practice Address - Street 1:4849 N MILWAUKEE AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-5100
Practice Address - Country:US
Practice Address - Phone:773-622-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019088271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty