Provider Demographics
NPI:1518962174
Name:VIENNE, PETER P JR (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:VIENNE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSHERE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:936 W US ROUTE 6
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-8858
Practice Address - Country:US
Practice Address - Phone:815-942-0525
Practice Address - Fax:815-942-3501
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082983207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL259912OtherHEALTH LINK
IL036082983Medicaid
IL3229984OtherBCBS
IL020438OtherHEALTH ALLIANCE
IL020438OtherHEALTH ALLIANCE
IL036082983Medicaid