Provider Demographics
NPI:1619144680
Name:MUTHALALY, ASHA S (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHA
Middle Name:S
Last Name:MUTHALALY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 N 129TH INFANTRY DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3171
Mailing Address - Country:US
Mailing Address - Phone:815-744-7246
Mailing Address - Fax:815-744-7346
Practice Address - Street 1:903 N 129TH INFANTRY DR
Practice Address - Street 2:SUITE 600
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3171
Practice Address - Country:US
Practice Address - Phone:815-744-7246
Practice Address - Fax:815-744-7346
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123531207RR0500X
IN01071250A207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213382OtherGROUP PTAN
IL036123531Medicaid
IL205574037OtherMEDICARE ID
ILF400128470Medicare PIN