Provider Demographics
NPI:1457383697
Name:FANTUS, RICHARD JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:FANTUS
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 1:836 W WELLINGTON AVE
Mailing Address - Street 2:4813 CENTER COURT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:773-296-7033
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Not Answered2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20054685Medicare ID - Type Unspecified
ILD16449Medicare UPIN