Healthcare Provider Details

I. General information

NPI: 1811987886
Provider Name (Legal Business Name): VASIL NIKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 N BLACKHAWK BLVD UNIVERSITY PRIMARY CARE CLINIC @ ROCKTON
ROCKTON IL
61072-1513
US

IV. Provider business mailing address

1511 N BLACKHAWK BLVD
ROCKTON IL
61072-1513
US

V. Phone/Fax

Practice location:
  • Phone: 815-624-2644
  • Fax: 815-624-2186
Mailing address:
  • Phone: 815-395-5879
  • Fax: 815-624-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036105887
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: