Provider Demographics
NPI:1639434814
Name:MOORTHY, GHURULAKSHMI (MD)
Entity Type:Individual
Prefix:DR
First Name:GHURULAKSHMI
Middle Name:
Last Name:MOORTHY
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 1:611 W PARK ST
Mailing Address - Street 2:CARLE FORUM LL
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-3110
Mailing Address - Fax:217-244-0621
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:CARLE FORUM LL
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3110
Practice Address - Fax:217-244-0621
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine