Provider Demographics
NPI:1043012016
Name:ANICIETE, JONATHAN (DO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:ANICIETE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-4240
Mailing Address - Country:US
Mailing Address - Phone:773-677-8246
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-0715
Practice Address - Country:US
Practice Address - Phone:708-783-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program