Healthcare Provider Details

I. General information

NPI: 1871762898
Provider Name (Legal Business Name): CLAUDE P OWIKOTI P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2008
Last Update Date: 02/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23813 E 3200 NORTH RD
DWIGHT IL
60420-8144
US

IV. Provider business mailing address

1696 WILLIAM DR
ROMEOVILLE IL
60446-1464
US

V. Phone/Fax

Practice location:
  • Phone: 815-584-2806
  • Fax: 815-584-3227
Mailing address:
  • Phone: 815-609-3804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85003157
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: