Healthcare Provider Details

I. General information

NPI: 1780176610
Provider Name (Legal Business Name): DEDEEPYA KONUTHULA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S. MARYLAND AVE MC 2007 B223
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

150 HARVESTER DR. STE 300
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.159969
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.159969
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: