Provider Demographics
NPI:1053321810
Name:DWIVEDI, SANJEEV (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:
Last Name:DWIVEDI
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 1:7 SALT CREEK LN
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2927
Mailing Address - Country:US
Mailing Address - Phone:630-850-2120
Mailing Address - Fax:630-850-2123
Practice Address - Street 1:7 SALT CREEK LN
Practice Address - Street 2:SUITE 206
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-2927
Practice Address - Country:US
Practice Address - Phone:630-850-2120
Practice Address - Fax:630-850-2123
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH05280Medicare UPIN