Provider Demographics
NPI:1194727420
Name:MATSESHE, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MATSESHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 FARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-2504
Mailing Address - Country:US
Mailing Address - Phone:847-855-3150
Mailing Address - Fax:
Practice Address - Street 1:1445 N HUNT CLUB RD STE 303
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2603
Practice Address - Country:US
Practice Address - Phone:847-855-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047991207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047991Medicaid
IL036047991Medicaid
ILD13774Medicare UPIN