Healthcare Provider Details

I. General information

NPI: 1811525389
Provider Name (Legal Business Name): BO WANG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W US ROUTE 6 STE B
MORRIS IL
60450-8854
US

IV. Provider business mailing address

725 SCHOOL ST STE A
MORRIS IL
60450-1207
US

V. Phone/Fax

Practice location:
  • Phone: 815-364-8927
  • Fax: 815-364-8928
Mailing address:
  • Phone: 815-941-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.076490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: