Provider Demographics
NPI:1467452755
Name:CLADIS, PETER D (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:D
Last Name:CLADIS
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 1:2425 FARGO BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3591
Mailing Address - Country:US
Mailing Address - Phone:630-232-2200
Mailing Address - Fax:630-232-1940
Practice Address - Street 1:2425 FARGO BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3591
Practice Address - Country:US
Practice Address - Phone:630-232-2200
Practice Address - Fax:630-232-1940
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA01867Medicare UPIN
ILP11327Medicare ID - Type UnspecifiedMEDICARE