Provider Demographics
NPI:1558636647
Name:SHIVAKUMAR, VIDYA (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:SHIVAKUMAR
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 1:839 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2631
Mailing Address - Country:US
Mailing Address - Phone:312-455-3500
Mailing Address - Fax:312-455-3502
Practice Address - Street 1:839 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2631
Practice Address - Country:US
Practice Address - Phone:312-455-3500
Practice Address - Fax:312-455-3502
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.059296207N00000X
IL036137305207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036137305OtherSTATE LICENSE