Healthcare Provider Details

I. General information

NPI: 1083816664
Provider Name (Legal Business Name): SUJATHA PRABHAKARAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19831 GOVERNORS HWY
FLOSSMOOR IL
60422-2001
US

IV. Provider business mailing address

19831 GOVERNORS HWY
FLOSSMOOR IL
60422-2001
US

V. Phone/Fax

Practice location:
  • Phone: 708-960-0907
  • Fax:
Mailing address:
  • Phone: 708-960-0907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036.167269
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: