Basic Information
| Provider Information | |||||||||
| NPI: | 1548678261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SITAULA | ||||||||
| FirstName: | SUJATA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6810 STATE ROUTE 162 | ||||||||
| Address2: | BOX 215 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916405 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Practice Location | |||||||||
| Address1: | 2133 VADALABENE DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182884350 | ||||||||
| FaxNumber: | 6182884296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2014 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 036149323 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.