Healthcare Provider Details

I. General information

NPI: 1609955715
Provider Name (Legal Business Name): DENNIS PAUL MLOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 BROADWAY ST
MOUNT VERNON IL
62864-2917
US

IV. Provider business mailing address

2413 BROADWAY ST
MOUNT VERNON IL
62864-2917
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-6559
  • Fax:
Mailing address:
  • Phone: 618-244-6559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number036105686
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: