Healthcare Provider Details

I. General information

NPI: 1235186958
Provider Name (Legal Business Name): SUDHA PRASAD M.D.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S KOKE MILL RD
SPRINGFIELD IL
62711-8012
US

IV. Provider business mailing address

901 S KOKE MILL RD
SPRINGFIELD IL
62711-8012
US

V. Phone/Fax

Practice location:
  • Phone: 214-546-4868
  • Fax: 217-698-9286
Mailing address:
  • Phone: 217-546-4868
  • Fax: 217-698-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SUDHA G PRASAD
Title or Position: DOCTOR
Credential: M.D.
Phone: 217-546-4868