Healthcare Provider Details

I. General information

NPI: 1326625070
Provider Name (Legal Business Name): GREGORY JOHN MOTZKUS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-300-3265
  • Fax:
Mailing address:
  • Phone: 801-300-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036178411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: