Provider Demographics
NPI:1093801508
Name:VIBHAKAR, NILLA (MD)
Entity Type:Individual
Prefix:DR
First Name:NILLA
Middle Name:
Last Name:VIBHAKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19999 ROCKSIDE ROAD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146
Practice Address - Country:US
Practice Address - Phone:216-524-7377
Practice Address - Fax:440-786-3841
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-049551208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0537084Medicaid
OH0537084Medicaid
VI4026611Medicare ID - Type Unspecified