Provider Demographics
NPI:1922014315
Name:SUSARLA, VISWANATHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:VISWANATHAM
Middle Name:
Last Name:SUSARLA
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 1:860 SUMMIT ST
Mailing Address - Street 2:STE 123
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-5145
Mailing Address - Country:US
Mailing Address - Phone:847-741-0026
Mailing Address - Fax:847-741-0027
Practice Address - Street 1:860 SUMMIT ST
Practice Address - Street 2:STE 123
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-5145
Practice Address - Country:US
Practice Address - Phone:847-741-0026
Practice Address - Fax:847-741-0027
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047106207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004500476OtherBLUE CROSS BLUE SHIELD
IL036047106Medicaid
IL112910380OtherRAILROAD MEDICARE
IL0004500476OtherBLUE CROSS BLUE SHIELD
IL112910380OtherRAILROAD MEDICARE