Provider Demographics
NPI:1770552192
Name:KOOIKER, PHILIP DEAN (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:DEAN
Last Name:KOOIKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16001 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8788
Mailing Address - Country:US
Mailing Address - Phone:708-460-0007
Mailing Address - Fax:708-460-0005
Practice Address - Street 1:16001 108TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8788
Practice Address - Country:US
Practice Address - Phone:708-460-0007
Practice Address - Fax:708-460-0005
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085389207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085389Medicaid
IL036085389Medicaid
IL449920Medicare PIN
ILL37212Medicare PIN