Healthcare Provider Details

I. General information

NPI: 1942263827
Provider Name (Legal Business Name): CHANDRASHEKHAR THUKRAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROXBURY RD
ROCKFORD IL
61107-5075
US

IV. Provider business mailing address

401 ROXBURY RD
ROCKFORD IL
61107-5075
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-7340
  • Fax: 815-397-7388
Mailing address:
  • Phone: 815-397-7340
  • Fax: 815-397-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number217223
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number217223
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number36117730
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: