Provider Demographics
NPI:1639285810
Name:PRINCIPE, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:PRINCIPE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11950 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1150
Mailing Address - Country:US
Mailing Address - Phone:708-448-9450
Mailing Address - Fax:708-448-9459
Practice Address - Street 1:11950 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1150
Practice Address - Country:US
Practice Address - Phone:708-448-9450
Practice Address - Fax:708-448-9459
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036071432207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C48759Medicare UPIN