Provider Demographics
NPI:1134561913
Name:INDLAMURI, MASTAN RAO (MD,)
Entity type:Individual
Prefix:
First Name:MASTAN RAO
Middle Name:
Last Name:INDLAMURI
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2239 E COOK ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-1944
Mailing Address - Country:US
Mailing Address - Phone:217-788-2300
Mailing Address - Fax:217-788-2342
Practice Address - Street 1:2239 E COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1944
Practice Address - Country:US
Practice Address - Phone:713-500-7616
Practice Address - Fax:713-500-7619
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.142622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036142622Medicaid