Provider Demographics
NPI:1154513505
Name:PETRUS, VAIDOTAS (MD)
Entity type:Individual
Prefix:
First Name:VAIDOTAS
Middle Name:
Last Name:PETRUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VAIDOTAS
Other - Middle Name:
Other - Last Name:PETRUSKEVICIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:STE LL7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3543
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:5145 N CALIFORNIA AVE STE M276
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:773-293-4171
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118601207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619784OtherBCBS#
1620633OtherBCBS#
IL336079735OtherCONTROLLED SUBSTANCE
IL336079735OtherCONTROLLED SUBSTANCE
FP0309270OtherDEA
K44577Medicare PIN