Healthcare Provider Details

I. General information

NPI: 1326314246
Provider Name (Legal Business Name): GEORGE C PONTIKIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 E OGDEN AVE
NAPERVILLE IL
60563-8609
US

IV. Provider business mailing address

1860 PAYSPHERE CIR
CHICAGO IL
60674-3328
US

V. Phone/Fax

Practice location:
  • Phone: 630-545-7565
  • Fax:
Mailing address:
  • Phone: 630-469-2000
  • 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 TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.062148
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036144518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: