Healthcare Provider Details

I. General information

NPI: 1275686891
Provider Name (Legal Business Name): SUJIT PRASAD SHRESTHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5666 E STATE ST
ROCKFORD IL
61108-2425
US

IV. Provider business mailing address

PO BOX 775925
CHICAGO IL
60677-5925
US

V. Phone/Fax

Practice location:
  • Phone: 815-226-2000
  • Fax:
Mailing address:
  • Phone: 815-226-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036.100085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: