Basic Information
| Provider Information | |||||||||
| NPI: | 1003805151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAPA | ||||||||
| FirstName: | VITTAL | ||||||||
| MiddleName: | VENKATA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 E DEAN ST | ||||||||
| Address2: | |||||||||
| City: | VIRDEN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626901446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179655481 | ||||||||
| FaxNumber: | 2179655640 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 E DEAN ST | ||||||||
| Address2: | |||||||||
| City: | VIRDEN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626901446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179655481 | ||||||||
| FaxNumber: | 2179655640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036052159 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.