Provider Demographics
NPI:1033315965
Name:DHAWAN, VIBHU (MD)
Entity Type:Individual
Prefix:DR
First Name:VIBHU
Middle Name:
Last Name:DHAWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E HINES PL APT 1C8
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-7453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2545 S BRUCE ST STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-1778
Practice Address - Country:US
Practice Address - Phone:702-732-2438
Practice Address - Fax:702-737-5043
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117862207R00000X, 208000000X, 208M00000X
NV19123207RN0300X
MO2011011351208M00000X
AZ53839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP #
ILP00617102OtherRR MEDICARE GROUP MEMBER PTAN
NV1033315965Medicaid
IL036117862Medicaid
ILCA4079OtherRR MEDICARE GROUP PTAN