Provider Demographics
NPI:1700830395
Name:PETKUS, RAYMOND W (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:W
Last Name:PETKUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 369
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-774-5588
Mailing Address - Fax:773-774-5591
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 369
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-774-5588
Practice Address - Fax:773-774-5591
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36-039826207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC41127Medicare UPIN
IL453063Medicare PIN