Provider Demographics
NPI:1689638595
Name:KAMALESH, MASOOR (MD)
Entity Type:Individual
Prefix:
First Name:MASOOR
Middle Name:
Last Name:KAMALESH
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 1:503 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2006
Mailing Address - Country:US
Mailing Address - Phone:217-342-3700
Mailing Address - Fax:
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2006
Practice Address - Country:US
Practice Address - Phone:217-342-3700
Practice Address - Fax:217-342-6286
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054786207RC0000X
IN01054786A207RC0001X, 207RC0200X
IL036.101397207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM47140345OtherMEDICARE PTAN
IN200370980Medicaid
IN060070329OtherRAILROAD MEDICARE
IN183380HHHMedicare PIN
IN060070329OtherRAILROAD MEDICARE