Provider Demographics
NPI:1336353671
Name:FORUTAN, MANUCHER MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:MANUCHER
Middle Name:MICHAEL
Last Name:FORUTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:MICHAEL
Other - Last Name:FORUTAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3911
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-8911
Mailing Address - Country:US
Mailing Address - Phone:630-717-7000
Mailing Address - Fax:630-717-7011
Practice Address - Street 1:600 S WASHINGTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6667
Practice Address - Country:US
Practice Address - Phone:630-717-7000
Practice Address - Fax:630-717-7011
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6584OtherMEDICARE RR
P00182546OtherMEDICARE RR
4029503OtherAETNA
P00182546OtherMEDICARE RR
D86596Medicare UPIN