Provider Demographics
NPI:1114112612
Name:KUTTY, RAFIQ M (MD)
Entity Type:Individual
Prefix:
First Name:RAFIQ
Middle Name:M
Last Name:KUTTY
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 1:675 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-366-7177
Mailing Address - Fax:708-366-3301
Practice Address - Street 1:7607 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-3513
Practice Address - Country:US
Practice Address - Phone:708-366-7177
Practice Address - Fax:708-366-3301
Is Sole Proprietor?:No
Enumeration Date:2007-09-09
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111644207RC0200X
IL036-111644207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202964OtherMEDICARE
IL036111644Medicaid
IL31601838OtherBLUE CROSS BLUE SHIELD
IL202963OtherMEDICARE