Provider Demographics
NPI:1942363049
Name:RAKALLA, CHARANJIT S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARANJIT
Middle Name:S
Last Name:RAKALLA
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 1:737 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4363
Mailing Address - Country:US
Mailing Address - Phone:217-442-2054
Mailing Address - Fax:
Practice Address - Street 1:737 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4363
Practice Address - Country:US
Practice Address - Phone:217-442-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B28682Medicare UPIN
225560Medicare PIN