Healthcare Provider Details

I. General information

NPI: 1235244336
Provider Name (Legal Business Name): LOKANATHAM GUMIDYALA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LOKANATHAM GUMIDYALA MD

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N COLLEGE AVE
GENESEO IL
61254-1091
US

IV. Provider business mailing address

600 N COLLEGE AVE
GENESEO IL
61254-1091
US

V. Phone/Fax

Practice location:
  • Phone: 309-944-6431
  • Fax:
Mailing address:
  • Phone: 309-944-6431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number36063714
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberN2099
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number45766
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: