Healthcare Provider Details

I. General information

NPI: 1093828212
Provider Name (Legal Business Name): SUDHAKAR R. YETURU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1357 W 103RD ST
CHICAGO IL
60643-2392
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 773-238-0800
  • Fax: 773-881-7239
Mailing address:
  • Phone: 847-390-5900
  • Fax: 708-636-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-085168
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: