Provider Demographics
NPI:1851601462
Name:BHAMIDIPATI, PRASANTA (MD)
Entity Type:Individual
Prefix:
First Name:PRASANTA
Middle Name:
Last Name:BHAMIDIPATI
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 1:301 N 8TH ST
Mailing Address - Street 2:PO BOX 19658
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:217-545-0130
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:217-545-0130
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126754208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126754Medicaid
IL036126754Medicaid