Provider Demographics
NPI:1376586420
Name:KVIETKUS, RACHELINA PORTOLESE (MD)
Entity Type:Individual
Prefix:
First Name:RACHELINA
Middle Name:PORTOLESE
Last Name:KVIETKUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3096
Mailing Address - Country:US
Mailing Address - Phone:574-237-9340
Mailing Address - Fax:574-239-1474
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-237-9340
Practice Address - Fax:574-239-1474
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01306109OtherRR MEDICARE
IN000000772015OtherBCBS BMG GOSHEN
IN200108300Medicaid
IN200108300Medicaid