Provider Demographics
NPI:1326184862
Name:VATZ, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:VATZ
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 1:1140 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2115
Mailing Address - Country:US
Mailing Address - Phone:847-612-1547
Mailing Address - Fax:847-441-7311
Practice Address - Street 1:1140 CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2115
Practice Address - Country:US
Practice Address - Phone:847-612-1547
Practice Address - Fax:847-441-7311
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360519002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051900Medicaid
ILC42137Medicare UPIN
IL483440Medicare PIN