Provider Demographics
NPI:1750557658
Name:PRADHAN, SANJEEV KUMAR (MD)
Entity type:Individual
Prefix:
First Name:SANJEEV
Middle Name:KUMAR
Last Name:PRADHAN
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 1:15538 ROYAL GLEN CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4577
Mailing Address - Country:US
Mailing Address - Phone:708-821-7794
Mailing Address - Fax:
Practice Address - Street 1:20060 GOVERNORS DR STE 100
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1029
Practice Address - Country:US
Practice Address - Phone:708-821-7794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-120607208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618941OtherBCBS
IL036120607Medicaid
IN200913040BMedicaid
IN200913040BMedicaid