Provider Demographics
NPI:1962413815
Name:MARIYAPPA, LATHA (MD)
Entity type:Individual
Prefix:
First Name:LATHA
Middle Name:
Last Name:MARIYAPPA
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 1:1535 S MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3434
Mailing Address - Country:US
Mailing Address - Phone:847-902-9125
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5216
Practice Address - Fax:773-564-5215
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108285207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-108285OtherIDFPR (ILLINOIS STATE MEDICAL LICENSE)
ILBM8971889OtherDEA