Provider Demographics
NPI:1902987076
Name:MALTEZOS, STAVROS NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:STAVROS
Middle Name:NICHOLAS
Last Name:MALTEZOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:DEPT 2299 PAYSPHERE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674
Mailing Address - Country:US
Mailing Address - Phone:630-725-9890
Mailing Address - Fax:630-725-0988
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:TOWER 1, SUITE 5M
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-725-9890
Practice Address - Fax:630-725-0988
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001617783OtherBLUE SHIELD OF ILLINOIS
IL0001617783OtherBLUE SHIELD OF ILLINOIS
ILC48985Medicare UPIN