Provider Demographics
NPI:1003805151
Name:CHAPA, VITTAL VENKATA (MD)
Entity Type:Individual
Prefix:DR
First Name:VITTAL
Middle Name:VENKATA
Last Name:CHAPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 E DEAN ST
Mailing Address - Street 2:
Mailing Address - City:VIRDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62690-1446
Mailing Address - Country:US
Mailing Address - Phone:217-965-5481
Mailing Address - Fax:217-965-5640
Practice Address - Street 1:138 E DEAN ST
Practice Address - Street 2:
Practice Address - City:VIRDEN
Practice Address - State:IL
Practice Address - Zip Code:62690-1446
Practice Address - Country:US
Practice Address - Phone:217-965-5481
Practice Address - Fax:217-965-5640
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC37736Medicare UPIN
ILP00246608Medicare Oscar/Certification
IL21872001Medicare PIN