Provider Demographics
NPI:1952359770
Name:YETTER, JOHN THOMAS (M D)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:YETTER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8531 FROST AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63134-1443
Mailing Address - Country:US
Mailing Address - Phone:314-761-1577
Mailing Address - Fax:
Practice Address - Street 1:200 HEALTH CARE DR
Practice Address - Street 2:STE 1501
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1154
Practice Address - Country:US
Practice Address - Phone:618-664-9830
Practice Address - Fax:618-664-9820
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063187174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036363187OtherIL LICENSE
IL810300008OtherMEDICARE OSCAR A
MO841619029OtherMISSOURI
IL810300008OtherMEDICARE OSCAR A