Provider Demographics
NPI:1942793740
Name:THYAGARAJAN, KAVYAMOL (DO)
Entity Type:Individual
Prefix:
First Name:KAVYAMOL
Middle Name:
Last Name:THYAGARAJAN
Suffix:
Gender:F
Credentials:DO
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:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1835 CTY RD C
Practice Address - Street 2:STE 150
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2723
Practice Address - Country:US
Practice Address - Phone:763-581-0340
Practice Address - Fax:763-581-0346
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072824207Q00000X
MN69960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine