Provider Demographics
NPI:1336122902
Name:FOTSO, CARMEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:T
Last Name:FOTSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:979 W MAIN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:WEST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-2095
Mailing Address - Country:US
Mailing Address - Phone:847-426-9396
Mailing Address - Fax:847-426-1086
Practice Address - Street 1:979 W MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-2095
Practice Address - Country:US
Practice Address - Phone:800-323-1743
Practice Address - Fax:847-426-1086
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036106098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106098Medicaid
ILH99695Medicare UPIN