Provider Demographics
NPI:1790724540
Name:VIJAYAKUMAR, ASHA N (MD)
Entity Type:Individual
Prefix:
First Name:ASHA
Middle Name:N
Last Name:VIJAYAKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 SCHILLER
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2885
Mailing Address - Country:US
Mailing Address - Phone:331-221-9001
Mailing Address - Fax:331-221-3971
Practice Address - Street 1:303 W. LAKE ST
Practice Address - Street 2:#200
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101
Practice Address - Country:US
Practice Address - Phone:331-221-9001
Practice Address - Fax:847-358-2770
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-107591Medicaid
ILH75482Medicare UPIN
IL036-107591Medicaid