Basic Information
Provider Information | |||||||||
NPI: | 1689661183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VONHAKE | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2601 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 629011031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185495361 | ||||||||
FaxNumber: | 6183514878 | ||||||||
Practice Location | |||||||||
Address1: | 2601 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 629011031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185495361 | ||||||||
FaxNumber: | 6183514878 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2005 | ||||||||
LastUpdateDate: | 02/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 036073211 | IL | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | 02004335A | IN | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 02004335B | 05 | IN |   | MEDICAID | 036073211 | 05 | IL |   | MEDICAID | 214881 | 01 | IL | MEDICARE GROUP PTAN | OTHER |