Healthcare Provider Details

I. General information

NPI: 1417105917
Provider Name (Legal Business Name): DOLAR R KOYA MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 THEODORE ST
CRESTHILL IL
60403
US

IV. Provider business mailing address

2215 THEODORE ST
CREST HILL IL
60403-5854
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-2000
  • Fax: 815-741-1001
Mailing address:
  • Phone: 815-741-2000
  • Fax: 815-741-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036055698
License Number StateIL

VIII. Authorized Official

Name: DOLAR R KOYA
Title or Position: OWNER
Credential: MD
Phone: 815-741-2000