Provider Demographics
NPI:1780731067
Name:OLTHOFF, ALLAN J (DO)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:J
Last Name:OLTHOFF
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 1:4524 S OAKENWALD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4514
Mailing Address - Country:US
Mailing Address - Phone:312-623-3007
Mailing Address - Fax:
Practice Address - Street 1:400 LAKE COOK RD
Practice Address - Street 2:200C
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5607
Practice Address - Country:US
Practice Address - Phone:847-267-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
205084Medicare ID - Type Unspecified
ILC43324Medicare UPIN