Provider Demographics
NPI:1063408631
Name:KALIVODA -POPELA, VICTORIA (DO)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:KALIVODA -POPELA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:POPELA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1000 W HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1007
Mailing Address - Country:US
Mailing Address - Phone:309-734-1414
Mailing Address - Fax:309-734-0323
Practice Address - Street 1:1000 W HARLEM AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1007
Practice Address - Country:US
Practice Address - Phone:309-734-1414
Practice Address - Fax:309-734-0323
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075881207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371352599001Medicaid
IL371352599001Medicaid
E30152Medicare UPIN
ILL78093Medicare ID - Type UnspecifiedCLINIC