Provider Demographics
NPI:1437141108
Name:VAIDYA, BHAVANA P (MD)
Entity Type:Individual
Prefix:
First Name:BHAVANA
Middle Name:P
Last Name:VAIDYA
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 1:10601 S KILBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5341
Mailing Address - Country:US
Mailing Address - Phone:708-425-2516
Mailing Address - Fax:
Practice Address - Street 1:6307 S STEWART AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3116
Practice Address - Country:US
Practice Address - Phone:773-962-4025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066303208100000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11871240OtherCAQH
IL711960OtherPTAN
IL316009776OtherBC
IL036066303Medicaid
AV2063117OtherDEA
IL316009776OtherBC