Provider Demographics
NPI:1043376569
Name:EKONG, EDWIN E (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:E
Last Name:EKONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10830 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3126
Mailing Address - Country:US
Mailing Address - Phone:773-264-1400
Mailing Address - Fax:773-264-1401
Practice Address - Street 1:10830 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3126
Practice Address - Country:US
Practice Address - Phone:773-264-1400
Practice Address - Fax:773-264-1401
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45518Medicare UPIN
IL681112Medicare ID - Type Unspecified