Provider Demographics
NPI:1437156999
Name:DODZIK, PETER A (PSYD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:DODZIK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W GOLF RD STE 16
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3923
Mailing Address - Country:US
Mailing Address - Phone:847-577-0904
Mailing Address - Fax:
Practice Address - Street 1:415 W GOLF RD STE 16
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3923
Practice Address - Country:US
Practice Address - Phone:847-577-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041718103TC0700X
IL071006408103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200406360Medicaid
IN680015841OtherRR MEDICARE
IN148730DMedicare PIN
P71994Medicare UPIN
IN148730DMedicare PIN
IN5506830003Medicare NSC
IN680015841Medicare PIN