Healthcare Provider Details

I. General information

NPI: 1609982990
Provider Name (Legal Business Name): DOLTON MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15437 COTTAGE GROVE AVE
DOLTON IL
60419-2742
US

IV. Provider business mailing address

15437 COTTAGE GROVE AVE
DOLTON IL
60419-2742
US

V. Phone/Fax

Practice location:
  • Phone: 708-841-1110
  • Fax: 708-841-8730
Mailing address:
  • Phone: 708-841-1110
  • Fax: 708-841-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateIL

VIII. Authorized Official

Name: EVANS FIAKPUI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 708-841-1110