Provider Demographics
NPI:1710275110
Name:DEOTALE, PRAVESH P (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVESH
Middle Name:P
Last Name:DEOTALE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5220 S 6TH STREET RD
Mailing Address - Street 2:1200 SUITE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5735
Mailing Address - Country:US
Mailing Address - Phone:217-545-7644
Mailing Address - Fax:217-585-6890
Practice Address - Street 1:5220 S 6TH STREET RD
Practice Address - Street 2:1200 SUITE
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-545-7644
Practice Address - Fax:217-585-6890
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2015-06-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL1250593322084P0800X
IL0361355822084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry