Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 36111189 | IL |
NPI | 1124005004 |
---|---|
Provider Name | Vikram C Prabhu |
First Address | Maywood, IL 60153 |
Second Address | Maywood, IL 60153 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/12/2005 |
Last Update Date | 04/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36111189 | (05) | IL |
H36926 | (02) |