Individual
MARCUS ISMEDHI MUTIDJO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APN
Contact information
Practice address
1701 W GARDEN ST, PEORIA, IL 61605
(309) 680-7600
(309) 680-7686
Mailing address
2214 N UNIVERSITY ST, PEORIA, IL 61604-3221
(309) 680-7669
(309) 681-8443
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
209016806
IL
Other
Enumeration date
06/03/2014
Last updated
01/14/2019
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