Provider Demographics
NPI:1982942942
Name:BOKTOR, ISAAC IBRAHIM
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:IBRAHIM
Last Name:BOKTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-5640
Mailing Address - Country:US
Mailing Address - Phone:309-673-0665
Mailing Address - Fax:
Practice Address - Street 1:221 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5640
Practice Address - Country:US
Practice Address - Phone:309-673-0665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-26
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist