Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 036052159 | IL |
Y | 111NI0900X | Internist | 036052159 | IL |
NPI | 1003805151 |
---|---|
Provider Name | Dr. Vittal Venkata Chapa |
First Address | Virden, IL 62690-1446 |
Second Address | Virden, IL 62690-1446 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2005 |
Last Update Date | 15/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C37736 | (02) | IL |