Provider Demographics
NPI:1376536615
Name:RAZDAN, AVTAR K I (MD)
Entity Type:Individual
Prefix:DR
First Name:AVTAR
Middle Name:K
Last Name:RAZDAN
Suffix:I
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 1:475 BROWN BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2325
Mailing Address - Country:US
Mailing Address - Phone:815-939-0003
Mailing Address - Fax:815-935-4908
Practice Address - Street 1:475 BROWN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2325
Practice Address - Country:US
Practice Address - Phone:815-939-0003
Practice Address - Fax:815-935-4908
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360488222080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04607499OtherBLUE CROSS BLUE SHIELD
IL036048822Medicaid
IL036048822Medicaid