Provider Demographics
NPI:1245240936
Name:KASTURI, PRAMILA (MD)
Entity Type:Individual
Prefix:
First Name:PRAMILA
Middle Name:
Last Name:KASTURI
Suffix:
Gender:F
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:PO BOX 291
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-0291
Mailing Address - Country:US
Mailing Address - Phone:847-249-1606
Mailing Address - Fax:847-249-1609
Practice Address - Street 1:15 TOWER CT STE 240
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3336
Practice Address - Country:US
Practice Address - Phone:847-249-1606
Practice Address - Fax:847-249-1609
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105457Medicaid
ILK29995Medicare PIN
IL036105457Medicaid
IL04932591OtherBLUE CROSS/SHIELD