Provider Demographics
NPI:1649287459
Name:MCCOY, DWIGHT MATTHEW (DC, CCSP)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:MATTHEW
Last Name:MCCOY
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 DEKALB AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3305
Mailing Address - Country:US
Mailing Address - Phone:815-895-5111
Mailing Address - Fax:815-895-5114
Practice Address - Street 1:1101 DEKALB AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3305
Practice Address - Country:US
Practice Address - Phone:815-895-5111
Practice Address - Fax:815-895-5114
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL33197Medicare PIN
ILU58744Medicare UPIN