Healthcare Provider Details

I. General information

NPI: 1740581776
Provider Name (Legal Business Name): SUSHMITA NALLAMOTHU PRATHIPATI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 LINCOLN HWY
ROCHELLE IL
61068-2613
US

IV. Provider business mailing address

510 LINCOLN HWY
ROCHELLE IL
61068-2613
US

V. Phone/Fax

Practice location:
  • Phone: 815-561-8335
  • Fax:
Mailing address:
  • Phone: 815-561-8335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number036132132
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125058229
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: