Healthcare Provider Details

I. General information

NPI: 1073942264
Provider Name (Legal Business Name): PADMA TIPIRNENI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17608 SAN BERNARDINO DR
ORLAND PARK IL
60467-8210
US

IV. Provider business mailing address

17608 SAN BERNARDINO DR
ORLAND PARK IL
60467-8210
US

V. Phone/Fax

Practice location:
  • Phone: 650-704-7523
  • Fax:
Mailing address:
  • Phone: 650-704-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036 046374
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: