Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 125.069376 | IL |
NPI | 1003267634 |
---|---|
Provider Name | Kavipriya Komeswaran |
First Address | Springfield, IL 62794-9635 |
Second Address | Springfield, IL 62701-1013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2016 |
Last Update Date | 24/06/2016 |