Provider Demographics
NPI:1821248881
Name:POOLA, VENKATESWARA P (MBBS)
Entity Type:Individual
Prefix:
First Name:VENKATESWARA
Middle Name:P
Last Name:POOLA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19677
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9677
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-0952
Practice Address - Street 1:315 W CARPENTER ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-0952
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-135600208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036135600Medicaid
MN020002879Medicare PIN
IL036135600Medicaid
ILF400169348Medicare PIN