Healthcare Provider Details

I. General information

NPI: 1992086433
Provider Name (Legal Business Name): GOPICHAND THREEPURANENI MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST UNIVERSITY OF ILLINOIS
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

401 W FULLERTON PKWY APPARTMENT 1706E
CHICAGO IL
60614-2868
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 773-280-1637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.060684
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: