Provider Demographics
NPI:1801203096
Name:SOORNEELA PRAKASH, SHRAWANI
Entity Type:Individual
Prefix:
First Name:SHRAWANI
Middle Name:
Last Name:SOORNEELA PRAKASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 W LAKE ST
Mailing Address - Street 2:1509
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601
Mailing Address - Country:US
Mailing Address - Phone:832-652-1934
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05837390200000X
IL125064642208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics