MARCUS ISMEDHI MUTIDJO APN NPI 1063825446

NPI Information

  • NPI: 1063825446
  • Provider Name: MARCUS ISMEDHI MUTIDJO, APN
  • Classification: Nurse Practitioner - 363LF0000X
  • Specialization: Family
  • Entity Type: Individual
  • PECOS Registration: Yes
  • Address: 1701 W GARDEN ST
    PEORIA, IL
    ZIP 61605
  • Phone: (309) 680-7600

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NPI Details

Marcus Ismedhi Mutidjo, APN is a family nurse practitioner in Peoria, IL. Marcus Ismedhi Mutidjo, APN NPI is 1063825446. The provider is registered as an individual entity type.

The NPPES NPI record indicates the provider is a male.

The provider's business location address is:

1701 W GARDEN ST
PEORIA, IL
ZIP 61605
Phone: (309) 680-7600
Fax: (309) 680-7686

The NPI 1063825446 is registered in the Medicare Provider, Enrollment, Chain and Ownership System (PECOS). The provider is legally eligible to order and refer Part B (Clinical Laboratory and Imaging), Durable Medical Equipment, Part A Home Health Agency (HHA), Power Mobility Devices.

The enumeration date for this NPI number is 6/3/2014 and was last updated on 1/14/2019.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1363LF0000XNurse PractitionerFamily209016806ILLINOISYes

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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