Provider Demographics
NPI:1285747634
Name:CHESTNUT, JULIAN S (DO)
Entity type:Individual
Prefix:
First Name:JULIAN
Middle Name:S
Last Name:CHESTNUT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 NIGHT OWL LN
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7460
Mailing Address - Country:US
Mailing Address - Phone:815-623-3756
Mailing Address - Fax:
Practice Address - Street 1:875 NIGHT OWL LN
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7460
Practice Address - Country:US
Practice Address - Phone:815-623-3756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-066070207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066070Medicaid
IL036066070Medicaid