Healthcare Provider Details

I. General information

NPI: 1467601583
Provider Name (Legal Business Name): MUTHUSWAMY DHIWAKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 8TH ST
SPRINGFIELD IL
62701-1041
US

IV. Provider business mailing address

PO BOX 19656
SPRINGFIELD IL
62794-9656
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-6544
Mailing address:
  • Phone: 217-545-8853
  • Fax: 217-545-0828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number125-054774
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: