Provider Demographics
NPI:1437291895
Name:LOPATKA, CRAIG WALTER (DDS, MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:WALTER
Last Name:LOPATKA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8254 N 2075 EAST RD
Mailing Address - Street 2:
Mailing Address - City:DOWNS
Mailing Address - State:IL
Mailing Address - Zip Code:61736-9547
Mailing Address - Country:US
Mailing Address - Phone:309-378-2045
Mailing Address - Fax:309-378-1430
Practice Address - Street 1:2502 E EMPIRE ST STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3739
Practice Address - Country:US
Practice Address - Phone:309-662-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0102741223S0112X
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF87297Medicare ID - Type Unspecified