Provider Demographics
NPI:1396270146
Name:CHAKRAVARTHY, SHRUTI (MD)
Entity type:Individual
Prefix:
First Name:SHRUTI
Middle Name:
Last Name:CHAKRAVARTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-655-3024
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2025-01-23
Deactivation Date:2017-12-04
Deactivation Code:
Reactivation Date:2017-12-18
Provider Licenses
StateLicense IDTaxonomies
IL036156737207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology