Provider Demographics
NPI:1588125876
Name:SRIVATSAN, SUDARSHAN (MD)
Entity type:Individual
Prefix:
First Name:SUDARSHAN
Middle Name:
Last Name:SRIVATSAN
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 1:7435 W TALCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3707
Mailing Address - Country:US
Mailing Address - Phone:773-990-5261
Mailing Address - Fax:
Practice Address - Street 1:7435 W TALCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3707
Practice Address - Country:US
Practice Address - Phone:978-846-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13315183-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology