Provider Demographics
NPI:1447245071
Name:PUNDALEEKA, SARODE K (MD)
Entity Type:Individual
Prefix:
First Name:SARODE
Middle Name:K
Last Name:PUNDALEEKA
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 1:2614 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-725-1355
Mailing Address - Fax:815-725-9857
Practice Address - Street 1:2614 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-725-1355
Practice Address - Fax:815-725-9857
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052030207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL98065OtherMEDICARE INDIV ID# FOR GROUP 205474
IL830000578OtherMEDICARE RR
IL036052030Medicaid
ILL29320OtherMEDICARE INDIV ID# FOR GROUP 336140
IL205474Medicare PIN
C45444Medicare UPIN
ILL29320OtherMEDICARE INDIV ID# FOR GROUP 336140