Healthcare Provider Details

I. General information

NPI: 1952806945
Provider Name (Legal Business Name): VINEEL BEZAWADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-1521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036.166653
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: