Provider Demographics
NPI:1972551513
Name:LOFTHOUSE, GERALD (MD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:LOFTHOUSE
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 278
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-0278
Mailing Address - Country:US
Mailing Address - Phone:630-410-2448
Mailing Address - Fax:630-410-8327
Practice Address - Street 1:402 W BOUGHTON RD STE F1
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1984
Practice Address - Country:US
Practice Address - Phone:630-410-2448
Practice Address - Fax:630-410-8327
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36058630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45574Medicare UPIN
ILC45574Medicare UPIN