Healthcare Provider Details

I. General information

NPI: 1003959933
Provider Name (Legal Business Name): ALLAN J OLTHOFF DO SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LAKE COOK RD 200C
DEERFIELD IL
60015-5607
US

IV. Provider business mailing address

4524 S OAKENWALD AVE
CHICAGO IL
60653-4514
US

V. Phone/Fax

Practice location:
  • Phone: 847-267-0260
  • Fax: 847-282-3862
Mailing address:
  • Phone: 312-623-3007
  • Fax: 847-282-3862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number036064582
License Number StateIL

VIII. Authorized Official

Name: DR. ALLAN J OLTHOFF
Title or Position: PRESIDENT
Credential: DO
Phone: 312-623-3007