Provider Demographics
NPI:1851503833
Name:BODDU, LAVANYA (MD)
Entity Type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:BODDU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:217-789-1403
Mailing Address - Fax:
Practice Address - Street 1:2512 HURST DR STE 120
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9200
Practice Address - Country:US
Practice Address - Phone:217-258-7590
Practice Address - Fax:217-258-3686
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121313207P00000X
IL036121313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121313OtherBLUE SHIELD
IL036121313-1Medicaid
IL036121313-1Medicaid