Provider Demographics
NPI:1013066257
Name:MITRAKUL, WIMOL ANN (MD)
Entity Type:Individual
Prefix:
First Name:WIMOL
Middle Name:ANN
Last Name:MITRAKUL
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:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0264
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1239 WINDHAM PKWY
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1608
Practice Address - Country:US
Practice Address - Phone:815-942-6323
Practice Address - Fax:779-210-5541
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
399980OtherGROUP MEDICARE PTAN
ILP00421865OtherRAILROAD MEDICARE PTAN
IL036111456Medicaid
ILP00421865OtherRAILROAD MEDICARE PTAN
IL036111456Medicaid