Provider Demographics
NPI:1437249182
Name:IGOLNIKOV, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:IGOLNIKOV
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:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:901 LINCOLNWAY
Practice Address - Street 2:SUITE 306
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3430
Practice Address - Country:US
Practice Address - Phone:219-324-0875
Practice Address - Fax:219-324-0827
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36108351207RG0100X
IN01071639A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151020007OtherMEDICARE PTAN
IN201096920Medicaid
IN000000782162OtherANTHEM BCBS
IL036108351Medicaid
IL036108351Medicaid
INBI9979103OtherDEA
ILK31170Medicare PIN