Provider Demographics
NPI:1245795293
Name:KITSLAAR, ANTHONY WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WILLIAM
Last Name:KITSLAAR
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 1:1250 EXECUTIVE PL STE 403
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2482
Mailing Address - Country:US
Mailing Address - Phone:630-302-3336
Mailing Address - Fax:
Practice Address - Street 1:1250 EXECUTIVE PL STE 403
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2482
Practice Address - Country:US
Practice Address - Phone:630-302-3336
Practice Address - Fax:630-232-4410
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360724362083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine