Provider Demographics
NPI:1588865778
Name:ILLUM, ANNIKA S (MD)
Entity type:Individual
Prefix:DR
First Name:ANNIKA
Middle Name:S
Last Name:ILLUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANNIKA
Other - Middle Name:SANDRA
Other - Last Name:ILLUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:17101 PRESTON RD STE 190-S
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1331
Mailing Address - Country:US
Mailing Address - Phone:214-377-7576
Mailing Address - Fax:214-377-7690
Practice Address - Street 1:17101 PRESTON RD STE 190-S
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1331
Practice Address - Country:US
Practice Address - Phone:214-377-7576
Practice Address - Fax:214-377-7690
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200464207RC0000X
TXP1086207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U3Z7OtherBCBS
TXTXB154614Medicare PIN
TXTXB154613Medicare PIN