Provider Demographics
NPI:1548254394
Name:LOUGHEAD, JEFFREY L (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:LOUGHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 152
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:630-933-6602
Mailing Address - Fax:630-933-6519
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1222
Practice Address - Country:US
Practice Address - Phone:630-933-2350
Practice Address - Fax:630-933-6519
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01091889A2080N0001X
IL036-0977182080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097718Medicaid
IL036097718Medicaid