Provider Demographics
NPI:1992917009
Name:KOGANTI, USHASRI
Entity type:Individual
Prefix:DR
First Name:USHASRI
Middle Name:
Last Name:KOGANTI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2106
Mailing Address - Country:US
Mailing Address - Phone:815-434-2048
Mailing Address - Fax:
Practice Address - Street 1:1129 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-2106
Practice Address - Country:US
Practice Address - Phone:815-434-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG93833Medicare UPIN
IL598870Medicare ID - Type Unspecified