Provider Demographics
NPI:1013915248
Name:CAMODECA, PATRICK J (DO)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:CAMODECA
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 1:10350 HALIGUS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9545
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:847-802-7112
Practice Address - Street 1:10350 HALIGUS RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-802-7112
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080930207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080930Medicaid
IL04532206OtherBLUE CROSS BLUE SHIELD
IL036080930OtherSTATE LICENSE
IL036080930Medicaid
ILK10444Medicare PIN
ILP00223993Medicare PIN
ILK10443Medicare PIN