Provider Demographics
NPI:1366903056
Name:THALLA, NIRGUNA (MD)
Entity type:Individual
Prefix:
First Name:NIRGUNA
Middle Name:
Last Name:THALLA
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 1:900 RAND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:350 S GREENLEAF ST STE 405
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5709
Practice Address - Country:US
Practice Address - Phone:847-336-3335
Practice Address - Fax:847-336-3249
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-171458208VP0000X
DCMTL005136390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine