Provider Demographics
NPI:1063825446
Name:MUTIDJO, MARCUS ISMEDHI (APN)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:ISMEDHI
Last Name:MUTIDJO
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7669
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:1701 W GARDEN ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-680-7686
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily