Provider Demographics
NPI:1265776165
Name:LAHOTI, SOURABH (MD)
Entity type:Individual
Prefix:
First Name:SOURABH
Middle Name:
Last Name:LAHOTI
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 1:1302 FRANKLIN AVE STE 2500
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6526
Mailing Address - Country:US
Mailing Address - Phone:309-268-2793
Mailing Address - Fax:309-268-3312
Practice Address - Street 1:840 PINE ST STE 880
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7525
Practice Address - Country:US
Practice Address - Phone:478-743-7092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-473712084N0400X, 2084V0102X
IL0361607952084V0102X
GA755742084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology