Provider Demographics
NPI:1104937960
Name:NUTAKOR, WORLALI MOSES (MD)
Entity type:Individual
Prefix:DR
First Name:WORLALI
Middle Name:MOSES
Last Name:NUTAKOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 SPYGLASS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-9639
Mailing Address - Country:US
Mailing Address - Phone:217-872-6134
Mailing Address - Fax:
Practice Address - Street 1:2310 E MOUND RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9640
Practice Address - Country:US
Practice Address - Phone:217-877-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103408207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103408-1Medicaid
IL036103408-1Medicaid