Healthcare Provider Details

I. General information

NPI: 1720126535
Provider Name (Legal Business Name): NICHOLAS GEORGE TZANETAKOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BOULDER HILL PASS
MONTGOMERY IL
60538
US

IV. Provider business mailing address

1256 WATERFORD DRIVE SUITE 230
AURORA IL
60504
US

V. Phone/Fax

Practice location:
  • Phone: 630-897-2848
  • Fax: 630-897-4498
Mailing address:
  • Phone: 630-499-2404
  • Fax: 630-499-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036066510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: