Provider Demographics
NPI:1659678076
Name:KADIYALA, LOLICHANDRA (MD)
Entity Type:Individual
Prefix:
First Name:LOLICHANDRA
Middle Name:
Last Name:KADIYALA
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 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-0353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:110 W CALENDAR AVE
Practice Address - Street 2:L
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2325
Practice Address - Country:US
Practice Address - Phone:516-353-7734
Practice Address - Fax:708-578-2408
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.126998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128998Medicaid