Provider Demographics
NPI:1649268053
Name:GOVINDAIAH, SUJATHA (MD)
Entity type:Individual
Prefix:DR
First Name:SUJATHA
Middle Name:
Last Name:GOVINDAIAH
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 1:4360 KENNEDY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4251
Mailing Address - Country:US
Mailing Address - Phone:309-796-1512
Mailing Address - Fax:309-796-1887
Practice Address - Street 1:4360 KENNEDY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4251
Practice Address - Country:US
Practice Address - Phone:309-796-1512
Practice Address - Fax:309-796-1887
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060186174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060186Medicaid
IL036060186Medicaid
D93832Medicare UPIN