Provider Demographics
NPI:1386681658
Name:THANGAVELU, MUTHIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:MUTHIAH
Middle Name:
Last Name:THANGAVELU
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 1:707 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-446-6410
Mailing Address - Fax:217-477-4757
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-446-6410
Practice Address - Fax:217-477-4757
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044903208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
177404OtherPERSONAL CARE/COVENTRY
IL036044903Medicaid
IN100014790AMedicaid
247893OtherUNITED HEALTHCARE
IL036044903Medicaid
IL281651Medicare ID - Type UnspecifiedILLINOIS MEDICARE
020007520Medicare ID - Type UnspecifiedRAILROAD MEDICARE