Healthcare Provider Details

I. General information

NPI: 1629066170
Provider Name (Legal Business Name): PHILIP FRANK ZUMWALT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S 4TH ST
WATSEKA IL
60970-1673
US

IV. Provider business mailing address

125 S 4TH ST
WATSEKA IL
60970-1673
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-5430
  • Fax: 815-432-6024
Mailing address:
  • Phone: 815-432-5430
  • Fax: 815-432-6024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036054820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: