Provider Demographics
NPI:1336192954
Name:SOWLLES, RICHARD PAUL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PAUL
Last Name:SOWLLES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:IL
Mailing Address - Zip Code:62341
Mailing Address - Country:US
Mailing Address - Phone:217-847-2693
Mailing Address - Fax:217-847-3980
Practice Address - Street 1:991 BROADWAY
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:IL
Practice Address - Zip Code:62341
Practice Address - Country:US
Practice Address - Phone:217-847-2693
Practice Address - Fax:217-847-3980
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01600419213E00000X
IA00489213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004196Medicaid
IL77850Medicare ID - Type Unspecified
T38985Medicare UPIN
IAI4672Medicare ID - Type Unspecified
IL0238600001Medicare NSC