Provider Demographics
NPI:1861762593
Name:THAGHALLI, SUNIL KUMAR SIDDEGOWDA (MD)
Entity type:Individual
Prefix:
First Name:SUNIL KUMAR
Middle Name:SIDDEGOWDA
Last Name:THAGHALLI
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 1:1111 SUPERIOR ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4138
Mailing Address - Country:US
Mailing Address - Phone:708-344-2161
Mailing Address - Fax:
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-344-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125057286207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine