Basic Information
| Provider Information | |||||||||
| NPI: | 1952742751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDRARAJU | ||||||||
| FirstName: | AVANTIKA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20970 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820037020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074326629 | ||||||||
| FaxNumber: | 3074326634 | ||||||||
| Practice Location | |||||||||
| Address1: | 3249 OAK PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477678368 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2013 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10581A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.