Healthcare Provider Details

I. General information

NPI: 1255337630
Provider Name (Legal Business Name): AJ PAMPALONE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 LEONARD DR STE 101
VALPARAISO IN
46383-7121
US

IV. Provider business mailing address

120 W 22ND ST STE 200
OAK BROOK IL
60523-1563
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-6001
  • Fax: 219-462-6060
Mailing address:
  • Phone: 630-575-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number02002618A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: