Healthcare Provider Details

I. General information

NPI: 1184116386
Provider Name (Legal Business Name): ARNAUD JEAN WAUTLET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST
CHICAGO IL
60611-5975
US

IV. Provider business mailing address

2024 W IOWA ST APT 3
CHICAGO IL
60622-5378
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8624
  • Fax:
Mailing address:
  • Phone: 312-618-3146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.072233
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036159272
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.072233
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: