Provider Demographics
NPI:1841285640
Name:THANDUPURAKAL, THOMAS VARGHESE (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:VARGHESE
Last Name:THANDUPURAKAL
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 1:248 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1630
Mailing Address - Country:US
Mailing Address - Phone:847-587-6333
Mailing Address - Fax:847-587-4839
Practice Address - Street 1:248 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1630
Practice Address - Country:US
Practice Address - Phone:847-587-6333
Practice Address - Fax:847-587-4839
Is Sole Proprietor?:No
Enumeration Date:2005-09-18
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-053505207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053505Medicaid
ILL20706Medicare UPIN