Provider Demographics
NPI:1265549174
Name:MORISETTY, VIDYA SAGAR RAO (MD)
Entity type:Individual
Prefix:
First Name:VIDYA SAGAR RAO
Middle Name:
Last Name:MORISETTY
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 1:675 E SNYDER DR STE 1
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4766
Mailing Address - Country:US
Mailing Address - Phone:217-875-1886
Mailing Address - Fax:217-875-3120
Practice Address - Street 1:675 E SNYDER DR STE 1
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4766
Practice Address - Country:US
Practice Address - Phone:217-875-1886
Practice Address - Fax:217-875-3120
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084779207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084779Medicaid
ILG60389Medicare UPIN
IL557190Medicare ID - Type Unspecified