Provider Demographics
NPI:1558543348
Name:GULATI, SURENDRA M (MD)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:M
Last Name:GULATI
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 1:2121 ONEIDA ST
Mailing Address - Street 2:#301
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-741-3942
Mailing Address - Fax:815-741-9712
Practice Address - Street 1:301 MADISON ST STE 300
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6664
Practice Address - Country:US
Practice Address - Phone:815-725-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360655412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065541Medicaid
ILD15077Medicare UPIN