Provider Demographics
NPI:1598824732
Name:KHANNA, VIKRAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:VIKRAM
Middle Name:J
Last Name:KHANNA
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 1:2430 ESPLANADE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5500
Mailing Address - Country:US
Mailing Address - Phone:847-458-7546
Mailing Address - Fax:
Practice Address - Street 1:2430 ESPLANADE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5500
Practice Address - Country:US
Practice Address - Phone:847-458-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-099868207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099862 1Medicaid
G92530Medicare UPIN
IL036099862 1Medicaid
IL214660 L70282Medicare ID - Type Unspecified