Healthcare Provider Details

I. General information

NPI: 1053575399
Provider Name (Legal Business Name): RAVI K PRAKASH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N HIGHLAND AVE
AURORA IL
60506-1404
US

IV. Provider business mailing address

28594 NETWORK PL
CHICAGO IL
60673-1285
US

V. Phone/Fax

Practice location:
  • Phone: 630-859-8700
  • Fax:
Mailing address:
  • Phone: 630-859-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036.138013
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.014359
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME118395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: