Basic Information
| Provider Information | |||||||||
| NPI: | 1720493877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATTA | ||||||||
| FirstName: | PRASANTH | ||||||||
| MiddleName: | BOBBY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 MIDLANDS CT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
| FaxNumber: | 8157567130 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 MIDLANDS CT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
| FaxNumber: | 8157567130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | FK5377355 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 208100000X | R3525 | KY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 036154765 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.