Provider Demographics
NPI:1629052485
Name:NIMAVAT, DHARMENDRA J (MD)
Entity Type:Individual
Prefix:
First Name:DHARMENDRA
Middle Name:J
Last Name:NIMAVAT
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 19676
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9676
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6844
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 4W16
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-757-6844
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1071342080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107134Medicaid
IL036107134Medicaid
IL256510091Medicare PIN