Basic Information
| Provider Information | |||||||||
| NPI: | 1659685329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VITTAL V CHAPA MD SC | ||||||||
| LastName: | |||||||||
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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: | 08/04/2010 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHAPA | ||||||||
| AuthorizedOfficialFirstName: | VITTAL | ||||||||
| AuthorizedOfficialMiddleName: | VENKATA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2179655481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 036052159 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.