Provider Demographics
NPI:1073589297
Name:IYENGAR, VIVEK (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:
Last Name:IYENGAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18425 W WEST CREEK DR
Mailing Address - Street 2:STE F
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6767
Mailing Address - Country:US
Mailing Address - Phone:708-444-8300
Mailing Address - Fax:708-444-8301
Practice Address - Street 1:18425 W WEST CREEK DR
Practice Address - Street 2:STE F
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6767
Practice Address - Country:US
Practice Address - Phone:708-444-8300
Practice Address - Fax:708-444-8301
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36106158174400000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH83606Medicare UPIN
ILK14037Medicare PIN