Provider Demographics
NPI:1568561074
Name:PEQUETTE, DEREK R (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:PEQUETTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 N CONVENT ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-8210
Practice Address - Country:US
Practice Address - Phone:815-936-1855
Practice Address - Fax:815-936-6097
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00886041OtherMEDICARE RAILROAD
ILP00886041OtherRR MEDICARE
ILP00886041OtherRR MEDICARE
ILP00886041OtherMEDICARE RAILROAD
ILP00447976Medicare PIN
IL216859235Medicare PIN