Healthcare Provider Details

I. General information

NPI: 1952678286
Provider Name (Legal Business Name): KRISHNA CHAITANYA KOTTAPALLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W LAKE ST
MELROSE PARK IL
60160-4039
US

IV. Provider business mailing address

260 E BUTTERFIELD RD APT 406
ELMHURST IL
60126-4581
US

V. Phone/Fax

Practice location:
  • Phone: 708-344-2161
  • Fax:
Mailing address:
  • Phone: 405-334-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60973
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125057310
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: