Provider Demographics
NPI:1134181829
Name:PETHKAR, SANJAY (MD)
Entity type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:PETHKAR
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:PO BOX 9200
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60567-0200
Mailing Address - Country:US
Mailing Address - Phone:815-609-3627
Mailing Address - Fax:815-609-1328
Practice Address - Street 1:13415 S ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5676
Practice Address - Country:US
Practice Address - Phone:815-609-3627
Practice Address - Fax:815-609-1328
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091255Medicaid
K40950Medicare PIN
IL036091255Medicaid