Provider Demographics
NPI:1295797470
Name:VENKATESAN, T K (MD)
Entity type:Individual
Prefix:
First Name:T
Middle Name:K
Last Name:VENKATESAN
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 809094
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-9094
Mailing Address - Country:US
Mailing Address - Phone:312-236-3642
Mailing Address - Fax:312-236-5162
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:#1107
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-236-3642
Practice Address - Fax:312-236-5162
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088143207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088143Medicaid
IL036088143Medicaid