Provider Demographics
NPI:1043390099
Name:PUPPALA, SHYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAM
Middle Name:
Last Name:PUPPALA
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 1:8 RED HILL LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-6188
Mailing Address - Country:US
Mailing Address - Phone:773-989-9868
Mailing Address - Fax:773-989-9824
Practice Address - Street 1:4755 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5015
Practice Address - Country:US
Practice Address - Phone:773-989-9868
Practice Address - Fax:773-989-9824
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360732812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073281Medicaid
IL211855Medicare ID - Type Unspecified
ILE18641Medicare UPIN