Provider Demographics
NPI:1053311407
Name:KAISTHA, VIVEK (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVEK
Middle Name:
Last Name:KAISTHA
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:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4119
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:6703 159TH ST
Practice Address - Street 2:103
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1781
Practice Address - Country:US
Practice Address - Phone:708-342-3000
Practice Address - Fax:708-342-3060
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088189Medicaid
IL350363Medicare PIN
IL324853Medicare PIN
ILF88533Medicare UPIN
IL036088189Medicaid
ILCE0256Medicare PIN