Basic Information
| Provider Information | |||||||||
| NPI: | 1417005968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOK | ||||||||
| FirstName: | CATHLEEN | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROWLEY | ||||||||
| OtherFirstName: | CATHLEEN | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1201 S MAIN ST | ||||||||
| Address2: | DEPT FPN | ||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196816995 | ||||||||
| FaxNumber: | 2197576481 | ||||||||
| Practice Location | |||||||||
| Address1: | 11161 RANDOLPH ST | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196629424 | ||||||||
| FaxNumber: | 2196627465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02003141A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.