Basic Information
| Provider Information | |||||||||
| NPI: | 1255380762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 954 WEST STATE STREET | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158959144 | ||||||||
| FaxNumber: | 8158994234 | ||||||||
| Practice Location | |||||||||
| Address1: | 954 WEST STATE STREET | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158959144 | ||||||||
| FaxNumber: | 8158994234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036102009 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036102009 | 05 | IL | MEDICAID |