Healthcare Provider Details

I. General information

NPI: 1164479424
Provider Name (Legal Business Name): CHARLES W LAGOSKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

9401 HOLY CROSS LN
BREESE IL
62230-3510
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-8818
  • Fax: 309-624-8820
Mailing address:
  • Phone: 618-526-7271
  • Fax: 618-526-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036060508
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036060508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: