Provider Demographics
NPI:1821227414
Name:AGRAWAL, VIKRAM (MD)
Entity Type:Individual
Prefix:
First Name:VIKRAM
Middle Name:
Last Name:AGRAWAL
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 1:600 JOHN DEERE RD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6869
Mailing Address - Country:US
Mailing Address - Phone:309-779-7900
Mailing Address - Fax:309-779-7905
Practice Address - Street 1:600 JOHN DEERE RD
Practice Address - Street 2:SUITE 308
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6869
Practice Address - Country:US
Practice Address - Phone:309-779-7900
Practice Address - Fax:309-779-7905
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123868208000000X
IAMD-41434208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123868Medicaid
IL036123868Medicaid