Provider Demographics
NPI:1124005004
Name:PRABHU, VIKRAM C (MD)
Entity type:Individual
Prefix:
First Name:VIKRAM
Middle Name:C
Last Name:PRABHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:(MAGUIRE CENTER, RM. 1900)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-8563
Mailing Address - Fax:708-216-4948
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(MAGUIRE CENTER, RM. 1900)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-8563
Practice Address - Fax:708-216-4948
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36111189207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36111189Medicaid
ILK08326Medicare ID - Type Unspecified
IL36111189Medicaid
ILK08325Medicare ID - Type Unspecified