Healthcare Provider Details

I. General information

NPI: 1659481562
Provider Name (Legal Business Name): SRINIVAS CHAKRAVARTHY KOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 S WEBER RD
BOLINGBROOK IL
60490-5451
US

IV. Provider business mailing address

3256 LAPP LN
NAPERVILLE IL
60564-8350
US

V. Phone/Fax

Practice location:
  • Phone: 630-378-9785
  • Fax: 630-348-9836
Mailing address:
  • Phone: 630-378-9785
  • Fax: 630-378-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036095253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: