Healthcare Provider Details

I. General information

NPI: 1144273665
Provider Name (Legal Business Name): PAUCHURU PRASADARAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 ELA RD SUITE 305
LAKE ZURICH IL
60047-2337
US

IV. Provider business mailing address

1412 JUSTIN CT
NAPERVILLE IL
60540-8365
US

V. Phone/Fax

Practice location:
  • Phone: 847-438-0181
  • Fax:
Mailing address:
  • Phone: 630-420-2425
  • Fax: 773-296-7821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: