Provider Demographics
NPI:1730276742
Name:UPPULURI, VENKATA SUBBA RAO (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:SUBBA RAO
Last Name:UPPULURI
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 1:17901 GOVERNORS HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1144
Mailing Address - Country:US
Mailing Address - Phone:708-957-0220
Mailing Address - Fax:708-957-4519
Practice Address - Street 1:17901 GOVERNORS HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1144
Practice Address - Country:US
Practice Address - Phone:708-957-0220
Practice Address - Fax:708-957-4519
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053509174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053509Medicaid
IL70390Medicare ID - Type Unspecified
IL036053509Medicaid