Provider Demographics
NPI:1841425568
Name:PORAYETTE, PRASHANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASHANTH
Middle Name:
Last Name:PORAYETTE
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 1:301 N 8TH ST
Mailing Address - Street 2:PO BOX 19661
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1041
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-8840
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:SUITE PAV 4A
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-8840
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1385142080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138514Medicaid
ILF400236795Medicare PIN