Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | IL | |
Y | 208600000X | Surgeon | IL |
NPI | 1013916089 |
---|---|
Provider Name | Bohdan Askold Iwanetz |
First Address | Dolton, IL 60419-1062 |
Second Address | Dolton, IL 60419-1062 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C43352 | (02) | IL |