Provider Demographics
NPI:1447452180
Name:KANDIKATTU, BHAVANA THOTA (MD)
Entity type:Individual
Prefix:DR
First Name:BHAVANA
Middle Name:THOTA
Last Name:KANDIKATTU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BHAVANA
Other - Middle Name:
Other - Last Name:THOTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-573-1167
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-573-1167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050396208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121510Medicaid
IL809840OtherMEDICARE GROUP PTAN
IL036121510Medicaid