Provider Demographics
NPI:1043215148
Name:TANQUILUT, EUGENE M (DO)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:M
Last Name:TANQUILUT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20060 GOVERNORS DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1029
Mailing Address - Country:US
Mailing Address - Phone:815-824-4406
Mailing Address - Fax:815-844-0307
Practice Address - Street 1:20060 GOVERNORS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1029
Practice Address - Country:US
Practice Address - Phone:815-824-4406
Practice Address - Fax:815-844-0307
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002492A2086S0129X
IL0360943412086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094341Medicaid
IL036094341Medicaid
ING37906Medicare UPIN
IL969780011Medicare PIN