Healthcare Provider Details

I. General information

NPI: 1205120136
Provider Name (Legal Business Name): ANJANA DWIVEDI ANJANA DWIVEDI, M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N MARINE DR
CHICAGO IL
60640
US

IV. Provider business mailing address

11781 LEE JACKSON MEMORIAL HWY STE 550
FAIRFAX VA
22033-3309
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8700
  • Fax:
Mailing address:
  • Phone: 571-777-5106
  • Fax: 703-563-6256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberNA
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: