Provider Demographics
NPI:1982816237
Name:VISHWANATH, ANU
Entity Type:Individual
Prefix:
First Name:ANU
Middle Name:
Last Name:VISHWANATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 W SIENNA LN APT 1208
Mailing Address - Street 2:APT 1208
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7854
Mailing Address - Country:US
Mailing Address - Phone:312-860-0315
Mailing Address - Fax:
Practice Address - Street 1:420 NE GLEN OAK AVE STE 401
Practice Address - Street 2:SUITE 401
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3168
Practice Address - Country:US
Practice Address - Phone:309-624-9844
Practice Address - Fax:309-624-8884
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.1324692080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program