Provider Demographics
NPI:1770509648
Name:LOPATKA, KEITH ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:LOPATKA
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 1:7300 W COLLEGE DR
Mailing Address - Street 2:STE 1NW
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1152
Mailing Address - Country:US
Mailing Address - Phone:708-671-1374
Mailing Address - Fax:708-671-1378
Practice Address - Street 1:7300 W COLLEGE DR
Practice Address - Street 2:STE 1NW
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1152
Practice Address - Country:US
Practice Address - Phone:708-671-1374
Practice Address - Fax:708-671-1378
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113547207N00000X
IN01056082A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-113547Medicaid
IN409160DMedicare ID - Type Unspecified
IL036-113547Medicaid
ILH84280Medicare UPIN