Healthcare Provider Details

I. General information

NPI: 1952359770
Provider Name (Legal Business Name): JOHN THOMAS YETTER M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH CARE DR STE 1501
GREENVILLE IL
62246-1154
US

IV. Provider business mailing address

8531 FROST AVE
BERKELEY MO
63134-1443
US

V. Phone/Fax

Practice location:
  • Phone: 618-664-9830
  • Fax: 618-664-9820
Mailing address:
  • Phone: 314-761-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036063187
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: