Provider Demographics
NPI:1447516638
Name:MLOT, ELLEN MICHELLE (DO)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MICHELLE
Last Name:MLOT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 SUMMIT STREET
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120
Mailing Address - Country:US
Mailing Address - Phone:847-742-6888
Mailing Address - Fax:847-742-8544
Practice Address - Street 1:1015 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4362
Practice Address - Country:US
Practice Address - Phone:847-742-6888
Practice Address - Fax:847-742-8544
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138495208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics