Healthcare Provider Details

I. General information

NPI: 1295090330
Provider Name (Legal Business Name): JOSE T KUZHIVELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2012
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 309-672-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036.137144
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: