Provider Demographics
NPI:1194325852
Name:OPPONG, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:OPPONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 W EASTWOOD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2969
Mailing Address - Country:US
Mailing Address - Phone:773-663-0924
Mailing Address - Fax:
Practice Address - Street 1:2555 W EASTWOOD AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2969
Practice Address - Country:US
Practice Address - Phone:773-663-0924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008670225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant