Individual
DR. BHAVANA THOTA KANDIKATTU
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
530 NE GLEN OAK AVE, PEORIA, IL 61637-0001
(309) 573-1167
Mailing address
530 NE GLEN OAK AVE, PEORIA, IL 61637-0001
(309) 573-1167
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
125050396
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036121510
—
IL
01
—
809840
MEDICARE GROUP PTAN
IL
Enumeration date
06/04/2007
Last updated
08/15/2023
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