Provider Demographics
NPI:1538268230
Name:PUTHENVEETIL, PETER JOSEPH (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOSEPH
Last Name:PUTHENVEETIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:401 GREENLEAF ST
Mailing Address - Street 2:STE 1
Mailing Address - City:PARK CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5744
Mailing Address - Country:US
Mailing Address - Phone:847-662-0978
Mailing Address - Fax:847-662-1395
Practice Address - Street 1:401 GREENLEAF ST
Practice Address - Street 2:STE 1
Practice Address - City:PARK CITY
Practice Address - State:IL
Practice Address - Zip Code:60085-5744
Practice Address - Country:US
Practice Address - Phone:847-662-0978
Practice Address - Fax:847-662-1395
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036108104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108104Medicaid
IL036108104Medicaid
H96812Medicare UPIN