Provider Demographics
NPI:1740581776
Name:PRATHIPATI, SUSHMITA NALLAMOTHU (MD)
Entity Type:Individual
Prefix:
First Name:SUSHMITA
Middle Name:NALLAMOTHU
Last Name:PRATHIPATI
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 1:510 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-2613
Mailing Address - Country:US
Mailing Address - Phone:815-561-8335
Mailing Address - Fax:
Practice Address - Street 1:510 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-2613
Practice Address - Country:US
Practice Address - Phone:815-561-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125058229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine