Provider Demographics
NPI:1518976323
Name:SUSARLA, SAVITHA (DO)
Entity Type:Individual
Prefix:DR
First Name:SAVITHA
Middle Name:
Last Name:SUSARLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 SUMMIT ST
Mailing Address - Street 2:STE 123
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-5145
Mailing Address - Country:US
Mailing Address - Phone:847-741-0026
Mailing Address - Fax:847-741-0027
Practice Address - Street 1:860 SUMMIT ST
Practice Address - Street 2:STE 123
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-5145
Practice Address - Country:US
Practice Address - Phone:847-741-0026
Practice Address - Fax:847-741-0027
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113639Medicaid
IL0004500476OtherBLUE CROSS BLUE SHIELD
ILP00292442OtherRAILROAD MEDICARE
ILI50841Medicare UPIN