Provider Demographics
NPI:1972604221
Name:MAMMOLITO, DENISE M (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:MAMMOLITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2037
Mailing Address - Country:US
Mailing Address - Phone:309-495-0250
Mailing Address - Fax:309-495-0276
Practice Address - Street 1:1001 MAIN STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2037
Practice Address - Country:US
Practice Address - Phone:309-495-0250
Practice Address - Fax:309-676-6545
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082251208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7215166OtherBCBS OF ILLINOIS
ILK35445OtherMEDICARE ID, TYPE UNSPEC
IL036082251Medicaid
ILK35445OtherMEDICARE ID, TYPE UNSPEC