Provider Demographics
NPI:1790932028
Name:MUTHARASAN, PRISCILLA ROCHE (MD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:ROCHE
Last Name:MUTHARASAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PRISCILLA
Other - Middle Name:ROSALYN
Other - Last Name:ROCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9977 WOODS DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9977 WOODS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1057
Practice Address - Country:US
Practice Address - Phone:847-663-8540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123424207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism