KELLY DIANE FORD MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****72

License Status

NOT RENEWED

Business

First Name

KELLY DIANE

Last Name

FORD

Suffix

Business Name

KELLY DIANE FORD MD

Original Issue Date

06/26/1996

Effective Date

06/26/1996

Expiration Date

07/31/1999

City

CHICAGO

State

Zip

60612

County

COOK

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

09/26/2006