Provider Demographics
NPI:1699797548
Name:MOPARTHI, VENKATA (MD)
Entity type:Individual
Prefix:MR
First Name:VENKATA
Middle Name:
Last Name:MOPARTHI
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 1:9223 W ST FRANCIS ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:815-806-3111
Mailing Address - Fax:815-464-2621
Practice Address - Street 1:335 E SIXTH ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:IL
Practice Address - Zip Code:60927
Practice Address - Country:US
Practice Address - Phone:815-936-5167
Practice Address - Fax:815-937-8246
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12956Medicare ID - Type Unspecified
I22272Medicare UPIN