Provider Demographics
NPI:1285201061
Name:BANIYA, KUSHAL BIKRAM (MD)
Entity Type:Individual
Prefix:
First Name:KUSHAL
Middle Name:BIKRAM
Last Name:BANIYA
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 1:5917 INVERNESS DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8704
Mailing Address - Country:US
Mailing Address - Phone:773-437-7028
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR STE 7100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5225
Practice Address - Fax:773-564-5226
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125078419207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine