Provider Demographics
NPI:1780662254
Name:GHANTOUS, WALID NASRI (MD)
Entity Type:Individual
Prefix:
First Name:WALID
Middle Name:NASRI
Last Name:GHANTOUS
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 1:343 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3251
Mailing Address - Country:US
Mailing Address - Phone:847-446-3200
Mailing Address - Fax:847-446-2934
Practice Address - Street 1:101 S GREENLEAF ST
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3369
Practice Address - Country:US
Practice Address - Phone:847-446-3200
Practice Address - Fax:847-446-2934
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-044591207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL461340Medicare ID - Type Unspecified
ILC39546Medicare UPIN