Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 038008803 | IL |
NPI | 1063583946 |
---|---|
Provider Name | Dr. Gus Spatharakis |
First Address | Park Ridge, IL 60068 |
Second Address | Park Ridge, IL 60068 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2006 |
Last Update Date | 28/07/2009 |