Provider Demographics
NPI:1366608341
Name:GUNNALA, SRI PREETHI (MD)
Entity type:Individual
Prefix:
First Name:SRI PREETHI
Middle Name:
Last Name:GUNNALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SRI PREETHI
Other - Middle Name:
Other - Last Name:VAGVALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:836 W WELLINGTON AVE
Mailing Address - Street 2:ILLINOIS MASONIC MEDICAL CENTER- DEPT OF RADIOLOGY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:772-296-7820
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:ILLINOIS MASONIC MEDICAL CENTER- DEPT OF RADIOLOGY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0361284032085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program