Provider Demographics
NPI:1790875417
Name:KILLOUGH, JOHN ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:KILLOUGH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 DEERPATH ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-8734
Mailing Address - Country:US
Mailing Address - Phone:217-348-3339
Mailing Address - Fax:217-348-3340
Practice Address - Street 1:1301 DEERPATH ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-8734
Practice Address - Country:US
Practice Address - Phone:217-348-3339
Practice Address - Fax:217-348-3340
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16005103213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01532005OtherBLUE CROSS BLUE SHIELD OF
IL016005103Medicaid
IL5630810001Medicare NSC
ILU71798Medicare UPIN
IL016005103Medicaid