Provider Demographics
NPI:1558473405
Name:CHANDUPATLA PROBHAKAR MD
Entity Type:Organization
Organization Name:CHANDUPATLA PROBHAKAR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHANDUPATLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRABHAKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-243-5474
Mailing Address - Street 1:559 N WESTGATE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650
Mailing Address - Country:US
Mailing Address - Phone:217-243-5474
Mailing Address - Fax:217-245-2322
Practice Address - Street 1:559 N WESTGATE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-243-5474
Practice Address - Fax:217-245-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210711Medicare ID - Type Unspecified