Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 036117862 | IL |
N | 111NI0900X | Internist | 036117862 | IL |
Y | 207R00000X | Internist | 53839 | AZ |
Y | 111NI0900X | Internist | 53839 | AZ |
N | 207RN0300X | Nephrologist | 19123 | NV |
N | 208000000X | Pediatrician | 036117862 | IL |
NPI | 1033315965 |
---|---|
Provider Name | Dr. Vibhu Dhawan |
First Address | Peoria, IL 61614-7453 |
Second Address | Las Vegas, NV 89169-1778 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2007 |
Last Update Date | 16/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036117862 | (05) | IL |
1033315965 | (05) | NV |
809840 | MEDICARE GROUP # (01) | IL |
CA4079 | RR MEDICARE GROUP PTAN (01) | IL |
P00617102 | RR MEDICARE GROUP MEMBER PTAN (01) | IL |