Provider Demographics
NPI:1235967472
Name:DASARI, PRANUTHI RATNA (MD)
Entity type:Individual
Prefix:
First Name:PRANUTHI RATNA
Middle Name:
Last Name:DASARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 COOPER AVE APT 308
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1178
Mailing Address - Country:US
Mailing Address - Phone:217-220-7073
Mailing Address - Fax:
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-220-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program