Healthcare Provider Details

I. General information

NPI: 1134569395
Provider Name (Legal Business Name): JACOB KALLIATH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE
OLYMPIA FIELDS IL
60461
US

IV. Provider business mailing address

10624 S. EASTERN AVE #263A
HENDERSON NV
89052
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2160
  • Fax: 708-679-2161
Mailing address:
  • Phone: 760-684-0407
  • Fax: 800-604-6214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR0057617
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02005206A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036138730
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12506386
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: