Provider Demographics
NPI:1710320189
Name:MIKKILINENI, VINAY KUMAR
Entity Type:Individual
Prefix:
First Name:VINAY
Middle Name:KUMAR
Last Name:MIKKILINENI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 KINGS RD
Mailing Address - Street 2:UNIT #3309
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-1316
Mailing Address - Country:US
Mailing Address - Phone:979-848-7169
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.140300207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine