Provider Demographics
NPI:1972501039
Name:THOTA, VIJAYALAKSHMI (DO)
Entity Type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:THOTA
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 1:12251 S. 80TH AVENUE, SUITE 1630
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-7874
Mailing Address - Fax:708-923-7876
Practice Address - Street 1:15300 WEST AVENUE, SUITE 223
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462
Practice Address - Country:US
Practice Address - Phone:708-923-7874
Practice Address - Fax:708-923-7876
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088719Medicaid
ILF96027Medicare UPIN
IL036088719Medicaid
ILK44349Medicare PIN