Provider Demographics
NPI:1720197346
Name:PRABHAKAR, CHANDUPATLA (MD)
Entity Type:Individual
Prefix:
First Name:CHANDUPATLA
Middle Name:
Last Name:PRABHAKAR
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 1:559 N WESTGATE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650
Mailing Address - Country:US
Mailing Address - Phone:217-243-5474
Mailing Address - Fax:217-245-2322
Practice Address - Street 1:559 N WESTGATE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-243-5474
Practice Address - Fax:217-245-2322
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056832Medicaid
IL036056832Medicaid
IL219970Medicare ID - Type Unspecified