Provider Demographics
NPI:1598841025
Name:MOTWANI, HARESH K (MD)
Entity Type:Individual
Prefix:DR
First Name:HARESH
Middle Name:K
Last Name:MOTWANI
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 1:2133 VADALABENE DR
Mailing Address - Street 2:SUITE # 5B
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5839
Mailing Address - Country:US
Mailing Address - Phone:618-288-7605
Mailing Address - Fax:618-288-7644
Practice Address - Street 1:2133 VADALABENE DR
Practice Address - Street 2:SUITE # 5B
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5839
Practice Address - Country:US
Practice Address - Phone:618-288-7605
Practice Address - Fax:618-288-7644
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.117061207Q00000X
IL036117061207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117061 5Medicaid
IL08232205OtherBLUE CROSS BLUE SHIELD
IL08232204OtherBLUE CROSS BLUE SHIELD
MO1598841025Medicaid
IL036117061Medicaid
MO1598841025Medicaid
ILIL1682011Medicare PIN
IL08232205OtherBLUE CROSS BLUE SHIELD
IL036117061 5Medicaid
ILK40377Medicare PIN