Provider Demographics
NPI:1790737781
Name:BUDDHARAJU, VENKATA (MD, FCCP)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:
Last Name:BUDDHARAJU
Suffix:
Gender:M
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 DE COOK AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1538
Mailing Address - Country:US
Mailing Address - Phone:773-505-3071
Mailing Address - Fax:773-975-1089
Practice Address - Street 1:840 W IRVING PARK RD
Practice Address - Street 2:305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-975-6775
Practice Address - Fax:773-975-1089
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-089871207R00000X
IL036089871207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635515OtherBCBS
ILH03090Medicare UPIN
IL01635515OtherBCBS