Provider Demographics
NPI:1790741148
Name:ILLERA, VIVIAN A (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:A
Last Name:ILLERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:ANA
Other - Last Name:ILLERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1921 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3405
Mailing Address - Country:US
Mailing Address - Phone:316-612-4815
Mailing Address - Fax:316-681-0244
Practice Address - Street 1:1921 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3405
Practice Address - Country:US
Practice Address - Phone:316-612-4815
Practice Address - Fax:316-681-0244
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25436207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100170460BMedicaid
KS100170460BMedicaid
A17716Medicare UPIN