Provider Demographics
NPI:1427067719
Name:LABOTKA, RICHARD J (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:LABOTKA
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:PO BOX 2506
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60017-2506
Mailing Address - Country:US
Mailing Address - Phone:312-415-4424
Mailing Address - Fax:847-390-8555
Practice Address - Street 1:536 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-3205
Practice Address - Country:US
Practice Address - Phone:312-415-4424
Practice Address - Fax:847-390-8555
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03655041208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
L93480Medicare PIN
D13596Medicare UPIN