Provider Demographics
NPI:1275882730
Name:KATTALAI KAILASAM, VASANTH (MD)
Entity Type:Individual
Prefix:
First Name:VASANTH
Middle Name:
Last Name:KATTALAI KAILASAM
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 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 SOUTH ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:779-220-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA607235872084P2900X
390200000X
MEMD219162084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program