Provider Demographics
NPI:1780687301
Name:KERSTAN, PETER D (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:KERSTAN
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 1:112 S NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4260
Mailing Address - Country:US
Mailing Address - Phone:847-696-3370
Mailing Address - Fax:
Practice Address - Street 1:205 S NORTHWEST HWY STE 130
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5802
Practice Address - Country:US
Practice Address - Phone:847-292-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080241Medicaid
IL389780Medicare ID - Type Unspecified
ILE18567Medicare UPIN