Provider Demographics
NPI:1063524676
Name:RAJAGOPAL, NIMMI
Entity type:Individual
Prefix:
First Name:NIMMI
Middle Name:
Last Name:RAJAGOPAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 W POLK ST STE 7808
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-413-8170
Mailing Address - Fax:312-864-3510
Practice Address - Street 1:4800 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3226
Practice Address - Country:US
Practice Address - Phone:773-826-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49210Medicare UPIN