Provider Demographics
NPI:1700872041
Name:PRAKASH, RAJAT (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJAT
Middle Name:
Last Name:PRAKASH
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 1:901 MCCLINTOCK DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0844
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:633-654-4253
Practice Address - Street 1:901 MCCLINTOCK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0844
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:633-654-4253
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-086830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-086-830Medicaid
IL036-086-830Medicaid
ILF72864Medicare UPIN
ILL86627Medicare PIN
ILL86626Medicare PIN