Basic Information
| Provider Information | |||||||||
| NPI: | 1609095520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADHWA | ||||||||
| FirstName: | NITIN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028999490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4123 DUTCHMANS LN STE 301 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028962500 | ||||||||
| FaxNumber: | 5028962527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 39290 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 39290 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201160960 | 05 | IN | MEDICAID | 50049164 | 01 | KY | PASSPORT - KCNS | OTHER | 000000805260 | 01 | KY | ANTHEM -KCNS | OTHER | 145059 | 01 | KY | SIHO - KCNS | OTHER | 7000033820 | 05 | KY | MEDICAID |