Provider Demographics
NPI:1780883843
Name:OLDHAM, NATHAN (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:OLDHAM
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 1:1201 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-1634
Mailing Address - Country:US
Mailing Address - Phone:618-297-9665
Mailing Address - Fax:618-297-9664
Practice Address - Street 1:1201 PINE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1634
Practice Address - Country:US
Practice Address - Phone:618-297-9665
Practice Address - Fax:618-297-9664
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013781207Q00000X
IL036125954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine