Provider Demographics
NPI:1053339259
Name:PELLETIERE, VINCENT JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JAMES
Last Name:PELLETIERE
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 1:1602 W COLONIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-1215
Mailing Address - Country:US
Mailing Address - Phone:847-358-9444
Mailing Address - Fax:847-358-8816
Practice Address - Street 1:1602 W COLONIAL PKWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60067-1215
Practice Address - Country:US
Practice Address - Phone:847-358-9444
Practice Address - Fax:847-358-8816
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Not Answered2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13264Medicare UPIN
ILK14541Medicare ID - Type Unspecified