Healthcare Provider Details

I. General information

NPI: 1053731802
Provider Name (Legal Business Name): DIVYASRI GONGIREDDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2014
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N MICHIGAN AVE STE 2250
CHICAGO IL
60611
US

IV. Provider business mailing address

625 N MICHIGAN AVE STE 2250
CHICAGO IL
60611-3348
US

V. Phone/Fax

Practice location:
  • Phone: 312-640-7740
  • Fax:
Mailing address:
  • Phone: 312-640-7740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.149609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: