Healthcare Provider Details

I. General information

NPI: 1851737779
Provider Name (Legal Business Name): JOHN LEUTHNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2013
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 E GRAND AVE
FOX LAKE IL
60020-1684
US

IV. Provider business mailing address

6615 GRAND AVE # 1037
GURNEE IL
60031-4591
US

V. Phone/Fax

Practice location:
  • Phone: 847-370-6712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01078547
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036150646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: