Provider Demographics
NPI:1003820820
Name:ZORETIC, NICHOLAS J (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:ZORETIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S GARY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2200
Mailing Address - Country:US
Mailing Address - Phone:630-924-4009
Mailing Address - Fax:630-924-9671
Practice Address - Street 1:245 S GARY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2200
Practice Address - Country:US
Practice Address - Phone:630-924-4009
Practice Address - Fax:630-924-9671
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3631498336019001OtherCDPG HFS PAYEE ID
IL363149833OtherTAX IDENTIFICATION NUMBER
IL0222075OtherBLUE CROSS GROUP NUMBER
IL036107388Medicaid
IL363149833OtherTAX IDENTIFICATION NUMBER
IL080192021Medicare PIN
IL0222075OtherBLUE CROSS GROUP NUMBER