Individual
DENISE M. MAMMOLITO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
12507 N HICKORY GROVE RD, DUNLAP, IL 61525-9411
(309) 696-1085
Mailing address
12507 N HICKORY GROVE RD, DUNLAP, IL 61525-9411
(309) 696-1085
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
036082251
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036082251
—
IL
01
—
7215166
BCBS OF ILLINOIS
IL
01
—
K35445
MEDICARE ID, TYPE UNSPEC
IL
Enumeration date
09/26/2006
Last updated
01/16/2025
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