Provider Demographics
NPI:1093777880
Name:DIDWANIA, SURESH K (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:K
Last Name:DIDWANIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:555 W COURT ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3664
Mailing Address - Country:US
Mailing Address - Phone:815-932-4614
Mailing Address - Fax:815-932-4615
Practice Address - Street 1:555 W COURT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3664
Practice Address - Country:US
Practice Address - Phone:815-932-4614
Practice Address - Fax:815-932-4615
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36093263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202872416OtherTAX ID
IL036093263Medicaid
ILF88739Medicare UPIN
IL396850Medicare ID - Type Unspecified
IL036093263Medicaid