Provider Demographics
NPI:1871961904
Name:MOFANG, HERMANNBRICE F
Entity type:Individual
Prefix:
First Name:HERMANNBRICE
Middle Name:F
Last Name:MOFANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HERMANN
Other - Middle Name:
Other - Last Name:MOFANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:2307 LA PORTE AVE.
Practice Address - Street 2:SUITE 5
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-6997
Practice Address - Country:US
Practice Address - Phone:219-477-4500
Practice Address - Fax:866-715-9733
Is Sole Proprietor?:No
Enumeration Date:2015-09-06
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014511A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist