Provider Demographics
NPI:1801081112
Name:VIJAYALAKSHMI THOTA DO SC
Entity type:Organization
Organization Name:VIJAYALAKSHMI THOTA DO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYALAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:THOTA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-349-6713
Mailing Address - Street 1:15300 WEST AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-349-6713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001627062OtherBC/BS
IL036088719Medicaid
IL0001627062OtherBC/BS
ILF96027Medicare UPIN
IL036088719Medicaid