Provider Demographics
NPI:1548678261
Name:SITAULA, SUJATA (MD)
Entity type:Individual
Prefix:
First Name:SUJATA
Middle Name:
Last Name:SITAULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:BOX 215
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8566
Mailing Address - Country:US
Mailing Address - Phone:618-391-6405
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:2133 VADALABENE DR STE 1
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5839
Practice Address - Country:US
Practice Address - Phone:618-288-4350
Practice Address - Fax:618-288-4296
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036149323207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL390200000XOtherSTUDENT IN AN ORGANIZED HEALTHCARE EDUCATION/TRAINING PROGRAM