Provider Demographics
NPI:1780747386
Name:TANQUILUT, RENATO L (MD)
Entity type:Individual
Prefix:DR
First Name:RENATO
Middle Name:L
Last Name:TANQUILUT
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 1:14005 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1824
Mailing Address - Country:US
Mailing Address - Phone:708-460-3072
Mailing Address - Fax:773-277-1166
Practice Address - Street 1:14005 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-1824
Practice Address - Country:US
Practice Address - Phone:708-460-3072
Practice Address - Fax:773-277-1166
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36043550208600000X
IN01041921A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021601990OtherBLUECROSSBLUESHIELD
IN000000198417OtherBLUECROSSBLUESHIELD
IN000000198417OtherBLUECROSSBLUESHIELD
IL0021601990OtherBLUECROSSBLUESHIELD
IL406770Medicare ID - Type Unspecified