Provider Demographics
NPI:1215266036
Name:PRAVINKUMAR, SUDHA (MD)
Entity type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:
Last Name:PRAVINKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUDHA
Other - Middle Name:
Other - Last Name:SADANAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2377 BLOOMINGTON AVE
Mailing Address - Street 2:STE B
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364
Mailing Address - Country:US
Mailing Address - Phone:815-672-1382
Mailing Address - Fax:815-672-5469
Practice Address - Street 1:2377 BLOOMINGTON AVE
Practice Address - Street 2:STE B
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364
Practice Address - Country:US
Practice Address - Phone:815-672-1382
Practice Address - Fax:815-672-5469
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.124024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine