Provider Demographics
NPI:1811418718
Name:THOMULKA, JONATHAN RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RUSSELL
Last Name:THOMULKA
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 1:1800 N WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1129
Mailing Address - Country:US
Mailing Address - Phone:818-424-5706
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.071515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine