Provider Demographics
NPI:1710151550
Name:HERETIS, KATHERINE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:HERETIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 E WOODFIELD RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4776
Mailing Address - Country:US
Mailing Address - Phone:847-605-0030
Mailing Address - Fax:847-637-0737
Practice Address - Street 1:7035 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1015
Practice Address - Country:US
Practice Address - Phone:708-680-3800
Practice Address - Fax:708-777-4776
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138161207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138161Medicaid
IL036138161Medicaid