Provider Demographics
NPI:1174144612
Name:DAFTARY, KARISHMA
Entity type:Individual
Prefix:
First Name:KARISHMA
Middle Name:
Last Name:DAFTARY
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 1:500 S PRESTON ST RM 305
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1702
Mailing Address - Country:US
Mailing Address - Phone:502-852-8696
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1600
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2997
Practice Address - Country:US
Practice Address - Phone:502-593-1017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.083084207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology