Provider Demographics
NPI:1194006742
Name:DEWILDE, POOJA SRINIVAS (DO)
Entity Type:Individual
Prefix:DR
First Name:POOJA
Middle Name:SRINIVAS
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:POOJA
Other - Middle Name:
Other - Last Name:KRISHNAPPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:10350 HALIGUS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9545
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:847-802-7203
Practice Address - Street 1:10350 HALIGUS RD STE 200
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-802-7203
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.060705207Q00000X
IL036134361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036134361OtherSTATE LICENSE