Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | 36106158 | IL |
NPI | 1073589297 |
---|---|
Provider Name | Vivek Iyengar |
First Address | Tinley Park, IL 60477-6767 |
Second Address | Tinley Park, IL 60477-6767 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2006 |
Last Update Date | 07/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H83606 | (02) | IL |