Healthcare Provider Details

I. General information

NPI: 1497913651
Provider Name (Legal Business Name): BETSY MALICAKAL EAPEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 TUSCANY DR
STREAMWOOD IL
60107-4531
US

IV. Provider business mailing address

1243 TUSCANY DR
STREAMWOOD IL
60107-4531
US

V. Phone/Fax

Practice location:
  • Phone: 917-348-4769
  • Fax: 224-238-7780
Mailing address:
  • Phone: 917-348-4769
  • Fax: 224-238-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036-125071
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number065357
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: