Provider Demographics
NPI:1821289315
Name:BHATTACHARYYA, PRIYA PULLUKAT (MD)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:PULLUKAT
Last Name:BHATTACHARYYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRIYA
Other - Middle Name:ANN
Other - Last Name:PULLUKAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:210 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-1418
Mailing Address - Country:US
Mailing Address - Phone:312-237-7606
Mailing Address - Fax:517-913-6712
Practice Address - Street 1:1540 LAKE LANSING RD STE 203
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3757
Practice Address - Country:US
Practice Address - Phone:517-913-6711
Practice Address - Fax:517-913-6712
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121103207Q00000X
MI4301508990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL729903009Medicare PIN