Provider Demographics
NPI:1063795128
Name:VENUGOPAL, KOTTARATHIL (MD)
Entity type:Individual
Prefix:
First Name:KOTTARATHIL
Middle Name:
Last Name:VENUGOPAL
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 1:55 E ERIE ST
Mailing Address - Street 2:UNIT 2102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2798
Mailing Address - Country:US
Mailing Address - Phone:312-915-0120
Mailing Address - Fax:
Practice Address - Street 1:55 E ERIE ST
Practice Address - Street 2:UNIT 2102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2798
Practice Address - Country:US
Practice Address - Phone:312-915-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.045592207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology