Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 036-056748 | IL |
NPI | 1154333961 |
---|---|
Provider Name | Dr. Vasireddy Bhoopal |
First Address | Orland Park, IL 60462-6117 |
Second Address | Palos Heights, IL 60463-2390 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036-056748 | ILLINOIS LICENCE NUMBER (01) | IL |
D 14324 | (02) | IL |