Provider Demographics
NPI:1720011752
Name:HOULAHAN, ROY F (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:F
Last Name:HOULAHAN
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 1:2357 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-6222
Mailing Address - Country:US
Mailing Address - Phone:630-859-6800
Mailing Address - Fax:
Practice Address - Street 1:80 TEMPLETON DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7000
Practice Address - Country:US
Practice Address - Phone:630-554-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107473Medicaid
IL0727500001Medicare NSC
H73888Medicare UPIN
ILL93965Medicare ID - Type Unspecified
ILL93964Medicare ID - Type Unspecified