Provider Demographics
NPI:1598702912
Name:MOSHOVITIS, CARL K (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:K
Last Name:MOSHOVITIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 N. CLAIFORNIA AVE.
Mailing Address - Street 2:SUITE 780-GMP
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3657
Mailing Address - Country:US
Mailing Address - Phone:773-989-3957
Mailing Address - Fax:
Practice Address - Street 1:5140 N. CALIFORNIA AVE.
Practice Address - Street 2:SUITE 780-GMP
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-989-3957
Practice Address - Fax:773-989-3971
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077963207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077963Medicaid
IL036077963Medicaid
E63927Medicare UPIN