Healthcare Provider Details

I. General information

NPI: 1174835003
Provider Name (Legal Business Name): PRASHANT JOLEPALEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

IV. Provider business mailing address

1001 AVENIDA PICO STE C #156
SAN CLEMENTE CA
92673-8198
US

V. Phone/Fax

Practice location:
  • Phone: 815-334-5566
  • Fax: 815-759-4008
Mailing address:
  • Phone: 248-762-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301096774
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number56922
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number275316
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA169326
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number56922
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number275316
License Number StateNY
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036134688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: