Provider Demographics
NPI:1801865332
Name:DWARAKANATHAN, SURENDAR (MD)
Entity Type:Individual
Prefix:
First Name:SURENDAR
Middle Name:
Last Name:DWARAKANATHAN
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 1:1750 W DIVISION ST APT 401
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8815
Mailing Address - Country:US
Mailing Address - Phone:708-860-5432
Mailing Address - Fax:773-245-5244
Practice Address - Street 1:320 W US HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1856
Practice Address - Country:US
Practice Address - Phone:708-860-5432
Practice Address - Fax:773-245-5244
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1649207W00000X
IL036-111537207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177348302Medicaid
I37193Medicare UPIN
TX177348302Medicaid