=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336122902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN T FOTSO-KOUATCHOU MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2005
-----------------------------------------------------
Last Update Date | 08/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 979 W MAIN ST STE 201
-----------------------------------------------------
City | WEST DUNDEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60118-2095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-323-1743
-----------------------------------------------------
Fax | 847-426-1086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29373 NETWORK PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-1293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036106098
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------