Healthcare Provider Details

I. General information

NPI: 1013051705
Provider Name (Legal Business Name): ISSAM MOUSSA MAATOUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N LINCOLN AVE STE 183
LINCOLNWOOD IL
60712-1736
US

IV. Provider business mailing address

3926 W TOUHY AVE # 372
LINCOLNWOOD IL
60712-1028
US

V. Phone/Fax

Practice location:
  • Phone: 224-766-7669
  • Fax:
Mailing address:
  • Phone: 847-810-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01041801A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-086819
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: