Provider Demographics
NPI:1285714568
Name:TATCH, WALTER
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:TATCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OSTERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4375
Mailing Address - Country:US
Mailing Address - Phone:847-623-5915
Mailing Address - Fax:847-623-1174
Practice Address - Street 1:310 S GREENLEAF ST STE 203
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5708
Practice Address - Country:US
Practice Address - Phone:847-623-5915
Practice Address - Fax:847-623-1174
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210020761223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU97440Medicare UPIN