Provider Demographics
NPI:1578608949
Name:VASELOPULOS, PETER THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:THOMAS
Last Name:VASELOPULOS
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 1:800 AUSTIN ST
Mailing Address - Street 2:SUITE 569E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-328-5600
Mailing Address - Fax:847-328-9129
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:SUITE 569
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-328-5600
Practice Address - Fax:847-328-9129
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090702208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090702Medicaid
IL036090702Medicaid
ILG13840Medicare UPIN