Healthcare Provider Details

I. General information

NPI: 1720493877
Provider Name (Legal Business Name): PRASANTH BOBBY KATTA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 MIDLANDS CT
SYCAMORE IL
60178-3125
US

IV. Provider business mailing address

2111 MIDLANDS CT
SYCAMORE IL
60178-3125
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-0000
  • Fax: 815-756-7130
Mailing address:
  • Phone: 815-758-0000
  • Fax: 815-756-7130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberFK5377355
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberR3525
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036154765
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036154765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: