Provider Demographics
NPI:1679764096
Name:MULLAPUDI, RAJENDRA PRASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJENDRA
Middle Name:PRASAD
Last Name:MULLAPUDI
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 1:3 SHENANDOAH CT
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0319
Mailing Address - Country:US
Mailing Address - Phone:630-926-5409
Mailing Address - Fax:
Practice Address - Street 1:1505 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1313
Practice Address - Country:US
Practice Address - Phone:872-208-6457
Practice Address - Fax:872-208-6459
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119143174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119143Medicaid