Provider Demographics
NPI:1619062809
Name:TODD TZANETOS, DEANNA RAE (MD)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:RAE
Last Name:TODD TZANETOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:RAE
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:200 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1831
Practice Address - Country:US
Practice Address - Phone:502-629-6000
Practice Address - Fax:502-629-5865
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39283207R00000X, 208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6412376300Medicaid
KYK078771Medicare PIN