=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144761404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDRA ILLUM MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17101 PRESTON RD STE 190S
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75248-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-500-1689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17101 PRESTON RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75248-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-377-7576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CARDIOLOGIST
-----------------------------------------------------
Name | DR. ANNIKA SANDRA ILLUM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 214-377-7576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | P1086
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | P1086
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------