Provider Demographics
NPI:1689627010
Name:MATHUR, VIRENDRA (MD)
Entity Type:Individual
Prefix:
First Name:VIRENDRA
Middle Name:
Last Name:MATHUR
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 1:4901 W 79TH. ST.
Mailing Address - Street 2:SUITE 5 MIDWAY INTERNAL MEDICINE S.C
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459
Mailing Address - Country:US
Mailing Address - Phone:708-952-4403
Mailing Address - Fax:708-952-4404
Practice Address - Street 1:4901 W 79TH. ST.
Practice Address - Street 2:SUITE 5 MIDWAY INTERNAL MEDICINE S.C
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459
Practice Address - Country:US
Practice Address - Phone:708-952-4403
Practice Address - Fax:708-952-4404
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075691Medicaid
IL036075691Medicaid
ILE98937Medicare UPIN