Provider Demographics
NPI:1508289745
Name:NEOFOTISTOS, PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:NEOFOTISTOS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 VILLAGE CENTER DR STE 205
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-4526
Mailing Address - Country:US
Mailing Address - Phone:630-920-4670
Mailing Address - Fax:
Practice Address - Street 1:20919 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-898-0800
Practice Address - Fax:630-920-4687
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012580111NR0400X, 111NS0005X, 111NX0100X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health