Provider Demographics
NPI:1134234305
Name:LIAKOS, PHOTINE (MD)
Entity type:Individual
Prefix:
First Name:PHOTINE
Middle Name:
Last Name:LIAKOS
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 1:2111 MIDLANDS CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3125
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-758-0094
Practice Address - Street 1:2111 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-758-0094
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-097169207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200031974OtherRAILROAD MEDICARE
IL035915OtherRAILROAD MEDICARE
IL0359580001OtherDMERC
IL01915167OtherBLUE CROSS/BLUE SHIELD
IL036097169Medicaid
IL200031974OtherRAILROAD MEDICARE
ILL62751Medicare ID - Type Unspecified