Provider Demographics
NPI:1659075109
Name:DUTKO, ALECSANDER
Entity Type:Individual
Prefix:
First Name:ALECSANDER
Middle Name:
Last Name:DUTKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 N BOOTZ AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2721 N BOOTZ AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2801
Practice Address - Country:US
Practice Address - Phone:815-992-1939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist