Provider Demographics
NPI:1215953369
Name:MULKI, M GHAITH (MD)
Entity type:Individual
Prefix:
First Name:M GHAITH
Middle Name:
Last Name:MULKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SILVER CROSS BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9603
Mailing Address - Country:US
Mailing Address - Phone:815-717-8737
Mailing Address - Fax:815-717-8699
Practice Address - Street 1:1890 SILVER CROSS BLVD STE 350
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9603
Practice Address - Country:US
Practice Address - Phone:815-717-8737
Practice Address - Fax:815-717-8699
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113818Medicaid
IL036113818Medicaid
I44660Medicare UPIN