Healthcare Provider Details

I. General information

NPI: 1366608341
Provider Name (Legal Business Name): SRI PREETHI GUNNALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SRI PREETHI VAGVALA MD

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE ILLINOIS MASONIC MEDICAL CENTER- DEPT OF RADIOLOGY
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

836 W WELLINGTON AVE ILLINOIS MASONIC MEDICAL CENTER- DEPT OF RADIOLOGY
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7820
  • Fax:
Mailing address:
  • Phone: 772-296-7820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number036128403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: