Healthcare Provider Details

I. General information

NPI: 1104937960
Provider Name (Legal Business Name): WORLALI MOSES NUTAKOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 E MOUND RD
DECATUR IL
62526-9640
US

IV. Provider business mailing address

775 SPYGLASS BLVD
FORSYTH IL
62535-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-0353
  • Fax:
Mailing address:
  • Phone: 217-872-6134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036103408
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036103408
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: