Provider Demographics
NPI:1851331185
Name:CAROPRESO, PHILIP RALPH (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:RALPH
Last Name:CAROPRESO
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 1:1813 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-2943
Mailing Address - Country:US
Mailing Address - Phone:319-524-3967
Mailing Address - Fax:
Practice Address - Street 1:630 LOCUST ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-1459
Practice Address - Country:US
Practice Address - Phone:217-357-2173
Practice Address - Fax:217-357-3610
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4128926Medicaid
MO2002004653OtherPROFESSIONAL LICENSE
IA20232OtherPROFESSIONAL LICENSE
IAI16700Medicare PIN
IAI16701Medicare ID - Type UnspecifiedNORIDIAN
ILK19036Medicare ID - Type UnspecifiedGRP NO 208627
IA20232OtherPROFESSIONAL LICENSE