Provider Demographics
NPI:1851428114
Name:TZANETAKOS SOLOMON, LISETTE (MD)
Entity Type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:
Last Name:TZANETAKOS SOLOMON
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 1:99 BOULDER HILL PASS
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538
Mailing Address - Country:US
Mailing Address - Phone:630-897-2848
Mailing Address - Fax:630-897-4498
Practice Address - Street 1:99 BOULDER HILL PASS
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538
Practice Address - Country:US
Practice Address - Phone:630-897-2848
Practice Address - Fax:630-897-4498
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073832Medicaid
D89945Medicare UPIN
IL036073832Medicaid