Provider Demographics
NPI:1851449060
Name:GUNARATNAM, LETTRICIA RAJIE (MD)
Entity type:Individual
Prefix:DR
First Name:LETTRICIA
Middle Name:RAJIE
Last Name:GUNARATNAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2863
Mailing Address - Country:US
Mailing Address - Phone:773-528-5400
Mailing Address - Fax:773-528-0607
Practice Address - Street 1:2143 W WELLINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-8288
Practice Address - Country:US
Practice Address - Phone:773-528-5400
Practice Address - Fax:773-528-0607
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336036066245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066245Medicaid
ILC48031Medicare UPIN
IL036066245Medicaid