Provider Demographics
NPI:1366461188
Name:MYKONIATIS, GABRIELLE EILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:EILEEN
Last Name:MYKONIATIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GABRIELLE
Other - Middle Name:EILEEN
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20939 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1620
Mailing Address - Country:US
Mailing Address - Phone:708-679-2770
Mailing Address - Fax:708-283-1137
Practice Address - Street 1:20939 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1620
Practice Address - Country:US
Practice Address - Phone:708-679-2770
Practice Address - Fax:708-283-1137
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00340OtherMEDICARE PTAN
OHI64755Medicare UPIN