Provider Demographics
NPI:1275093734
Name:VENKATESULU, BHANUPRASAD (MD)
Entity Type:Individual
Prefix:
First Name:BHANUPRASAD
Middle Name:
Last Name:VENKATESULU
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 1:6016 S ARCHER RD APT 12
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-2054
Mailing Address - Country:US
Mailing Address - Phone:832-275-4272
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:832-275-4272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.0753992085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1275093734Medicaid