Provider Demographics
NPI:1417058256
Name:PUTHENVEETIL, ELIZABETH J (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:PUTHENVEETIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:J
Other - Last Name:MATHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1707 N HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1320
Mailing Address - Country:US
Mailing Address - Phone:309-343-1000
Mailing Address - Fax:309-344-1054
Practice Address - Street 1:1707 N HENDERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1320
Practice Address - Country:US
Practice Address - Phone:309-343-1000
Practice Address - Fax:309-344-1054
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7191392OtherAETNA
IL11053987OtherCAQH
364271985-29OtherJOHN DEERE
4815127OtherBC/BS
7191392OtherAETNA
364271985-29OtherJOHN DEERE