Provider Demographics
NPI:1619135233
Name:MULTACK, SAMUEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:MULTACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9251
Mailing Address - Country:US
Mailing Address - Phone:815-462-1962
Mailing Address - Fax:
Practice Address - Street 1:4001 VOLLMER RD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-3168
Practice Address - Country:US
Practice Address - Phone:708-747-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-124776207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124776Medicaid