Provider Demographics
NPI:1336256437
Name:VENETOS, KATINA C (MD)
Entity Type:Individual
Prefix:DR
First Name:KATINA
Middle Name:C
Last Name:VENETOS
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 1:800 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 100C
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-234-1177
Mailing Address - Fax:847-234-1875
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:SUITE 100C
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-234-1177
Practice Address - Fax:847-234-1875
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01608107OtherBLUE CROSS BLUE SHIELD
ILG32656Medicare UPIN
IL01608107OtherBLUE CROSS BLUE SHIELD
ILK40884Medicare PIN
ILK40085Medicare PIN