Healthcare Provider Details

I. General information

NPI: 1386732980
Provider Name (Legal Business Name): PRABHAMANI IYER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MILLER RD
STERLING IL
61081-1252
US

IV. Provider business mailing address

101 E MILLER RD
STERLING IL
61081-1252
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-4790
  • Fax:
Mailing address:
  • Phone: 815-625-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036053066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: