Provider Demographics
NPI:1720344526
Name:TAMRAGOURI, PRASHANTH RAVIKIRAN (MD)
Entity Type:Individual
Prefix:
First Name:PRASHANTH
Middle Name:RAVIKIRAN
Last Name:TAMRAGOURI
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 1:1909 OGDEN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2602
Mailing Address - Country:US
Mailing Address - Phone:630-750-7920
Mailing Address - Fax:
Practice Address - Street 1:1909 OGDEN AVE STE A
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2602
Practice Address - Country:US
Practice Address - Phone:630-750-7920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361380172084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry