Provider Demographics
NPI:1053567891
Name:MEDAVARAM, DEEPIKA
Entity type:Individual
Prefix:
First Name:DEEPIKA
Middle Name:
Last Name:MEDAVARAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 BRANDONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5554
Mailing Address - Country:US
Mailing Address - Phone:217-793-3185
Mailing Address - Fax:
Practice Address - Street 1:3400 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7917
Practice Address - Country:US
Practice Address - Phone:217-787-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001007224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant