Healthcare Provider Details

I. General information

NPI: 1083637771
Provider Name (Legal Business Name): VISHWANATH AGRAWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

752 CENTURY FARM LN
NAPERVILLE IL
60563-2586
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4063
  • Fax: 312-864-9943
Mailing address:
  • Phone: 630-548-2748
  • Fax: 312-964-9943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-085966
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-085966
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: