Provider Demographics
NPI:1588985196
Name:PULLELA, SWATHI (DO)
Entity type:Individual
Prefix:
First Name:SWATHI
Middle Name:
Last Name:PULLELA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3605
Practice Address - Fax:217-383-2704
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036158715207RN0300X
OH34.012296207RN0300X
KY03995207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01729175OtherRR MEDICARE
KY7100433230Medicaid
OH0179603Medicaid
KY000001053047OtherANTHEM BCBS
OHP01727533OtherRR MEDICARE
KYP01729175OtherRR MEDICARE
KY000001053047OtherANTHEM BCBS