Provider Demographics
NPI:1760547889
Name:MAZUMDAR, AVI (MD)
Entity Type:Individual
Prefix:DR
First Name:AVI
Middle Name:
Last Name:MAZUMDAR
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 1:25 N WINFIELD RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-2113
Mailing Address - Fax:630-933-4520
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:SUITE 500
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-2113
Practice Address - Fax:630-933-4520
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020211692084N0400X
IL0361138852085N0700X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00762032OtherRR MEDICARE (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
MO207599606Medicaid
IL036113885Medicaid
ILK35062OtherMEDICARE PTAN (INDIVIDUAL)
ILP00762032OtherRR MEDICARE (INDIVIDUAL)