Individual
DR. SREENIVASA BASAVANTHAPPA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2501 E COLLEGE AVE STE B, BLOOMINGTON, IL 61704-2484
(309) 557-8666
(309) 827-8027
Mailing address
1008 N MAIN ST, BLOOMINGTON, IL 61701-1784
(309) 557-8666
(309) 661-0545
Taxonomy
Speciality
Code
Description
License number
State
207WX0107X
Retina Specialist (Ophthalmology) Physician
Primary
03-6163408
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110096239A
—
MA
Enumeration date
07/06/2007
Last updated
12/28/2023
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