Provider Demographics
NPI:1689914954
Name:MONTICCIOLO, MICHAEL THOMAS (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MONTICCIOLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350
Mailing Address - Country:US
Mailing Address - Phone:815-433-3100
Mailing Address - Fax:815-433-0879
Practice Address - Street 1:1100 E NORRIS DR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350
Practice Address - Country:US
Practice Address - Phone:815-433-3100
Practice Address - Fax:815-433-0879
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020253207P00000X
390200000X
IL036172367207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program