Healthcare Provider Details

I. General information

NPI: 1316142755
Provider Name (Legal Business Name): RAJA IRFAN SADIQ M,D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 N LOGAN AVE
DANVILLE IL
61832-4369
US

IV. Provider business mailing address

735 N LOGAN AVE
DANVILLE IL
61832-4369
US

V. Phone/Fax

Practice location:
  • Phone: 217-443-9100
  • Fax: 217-443-6792
Mailing address:
  • Phone: 217-443-9100
  • Fax: 217-443-6792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036121961
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036121961
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: