Healthcare Provider Details

I. General information

NPI: 1811272149
Provider Name (Legal Business Name): KIRAN KUMAR YELAKANTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 HURST DR STE 130
MATTOON IL
61938-9200
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-7590
  • Fax: 217-258-3686
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number276624
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036153492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: