Provider Demographics
NPI:1477181071
Name:VARGHESE, KEVIN CHACKO (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHACKO
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 S KENNEDY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2682
Mailing Address - Country:US
Mailing Address - Phone:815-937-1237
Mailing Address - Fax:815-933-0662
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-933-1671
Practice Address - Fax:815-933-0662
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361712732084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program