Provider Demographics
NPI:1154333961
Name:BHOOPAL, VASIREDDY (MD,)
Entity Type:Individual
Prefix:DR
First Name:VASIREDDY
Middle Name:
Last Name:BHOOPAL
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 1:14125 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-6117
Mailing Address - Country:US
Mailing Address - Phone:708-466-9039
Mailing Address - Fax:
Practice Address - Street 1:12800 S RIDGELAND AVE
Practice Address - Street 2:SUITE E
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2390
Practice Address - Country:US
Practice Address - Phone:708-388-4911
Practice Address - Fax:708-388-4933
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056748207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-056748OtherILLINOIS LICENCE NUMBER
IL036-056748OtherILLINOIS LICENCE NUMBER
649180Medicare ID - Type UnspecifiedMEDICARE