Provider Demographics
NPI:1417105917
Name:DOLAR R KOYA MD SC
Entity Type:Organization
Organization Name:DOLAR R KOYA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOLAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-2000
Mailing Address - Street 1:2215 THEODORE ST
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-5854
Mailing Address - Country:US
Mailing Address - Phone:815-741-2000
Mailing Address - Fax:815-741-1001
Practice Address - Street 1:2215 THEODORE ST
Practice Address - Street 2:
Practice Address - City:CRESTHILL
Practice Address - State:IL
Practice Address - Zip Code:60403
Practice Address - Country:US
Practice Address - Phone:815-741-2000
Practice Address - Fax:815-741-1001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOLAR R KOYA MD SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055698207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43082Medicare UPIN