Active NPI 1063825446 Individual Practitioner Male Practitioner

Marcus Ismedhi Mutidjo , APN

Nurse Practitioner - Family • Peoria, IL

Professional Overview & Biography Verified Profile Summary

Marcus Mutidjo, APN is a registered healthcare professional specializing in Nurse Practitioner - Family in Peoria, IL. Practice services are available at 1701 W GARDEN ST under active NPI credentials.

Practice Location & Contact Primary Location

Practice Address

1701 W Garden St

Peoria, IL 61605

Telephone 3096807600

Fax 3096807686

Associated Practice Facility / Clinic

🏢 Heartland Community Health Clinic Facility NPI 1336193861

Specialty Benchmarks & Practice Insights

Comparative analytics for Nurse Practitioner - Family in Peoria, IL

Active Practitioner

Practitioner Clinical Experience

Active

City Avg: 8.9 Yrs

State Avg: 8.9 Yrs

Regional Practice Density

216 Specialists

Practicing in Peoria, IL (7705 Statewide)

Telehealth Adoption Rate

16.7% Regional Adoption

In-Person Office Visits Only

Medicare Pricing Discount

67.4% Avg Savings

Under CMS Medicare Fee Schedule vs Standard Submitted Charges

Medical Specialties & State Licenses

Nurse Practitioner - Family Primary Specialty

NUCC Taxonomy Code: 363LF0000X

State License IL 209016806

Definition to come...

Practice Associates & Co-Workers

Healthcare professionals and specialists practicing at this location or sharing practice phone/fax

40 Associated Practitioners

Dr. Sarah Koscica , MD

Family Medicine

NPI 1003814625

Doctor of Medicine (M.D.)

Dr. Ann Parkin-Cohen , MD

Pediatrics

NPI 1033405469

Doctor of Medicine (M.D.)

Edward Etherton , NP

Nurse Practitioner

NPI 1053662783

Nurse Practitioner

Dr. M. Fraser , MD

Psychiatry & Neurology - Neurology

NPI 1093928566

Doctor of Medicine (M.D.)

Madeline Gresham , WHNP

Nurse Practitioner - Women's Health

NPI 1124748009

Women's Health Nurse Practitioner

Dr. John Mihelcic , MD

Family Medicine

NPI 1134582521

Doctor of Medicine (M.D.)

Career & Practice History Timeline

Chronological log of verified NPI updates, location relocations, credentials, and registry changes

14 Historical Events

📍

Updated Practice Location August 28, 2018

Registered at 1701 W GARDEN ST, PEORIA, IL 61605 (Tel: 3096807600)

📍

Updated Business Mailing Address August 28, 2018

Registered at 2214 N UNIVERSITY ST, PEORIA, IL 616043221 (Tel: 3096807669)

👤

Provider Name / Credentials Updated August 28, 2018

Recorded as MARCUS MUTIDJO, APN

✅

NPI Profile Active February 01, 2018

NPI status registered as active in NPPES database

📍

Updated Practice Location February 01, 2018

Registered at 819 BLOOMINGTON RD, CHAMPAIGN, IL 618202101 (Tel: 2174035498)

📍

Updated Business Mailing Address February 01, 2018

Registered at 2114 S ORCHARD ST, URBANA, IL 618016566

👤

Provider Name / Credentials Updated February 01, 2018

Recorded as MARCUS MUTIDJO

🎓

Medical Taxonomy / Specialty Registered (Primary Specialty) February 01, 2018

Nurse Practitioner (License #209016806 in IL)

✅

NPI Profile Active June 03, 2014

NPI status registered as active in NPPES database

📍

Updated Practice Location June 03, 2014

Registered at 601 SUNLAND PARK DR, BLDG ONE, EL PASO, TX 799125131 (Tel: 9155331622)

📍

Updated Business Mailing Address June 03, 2014

Registered at 626 S ZARZAMORA ST, SAN ANTONIO, TX 782075254

👤

Provider Name / Credentials Updated June 03, 2014

Recorded as MARCUS MUTIDJO

🎓

Medical Taxonomy / Specialty Registered (Primary Specialty) June 03, 2014

Clinical Nurse Specialist (License #AP123153 in TX)

🟢

Initial NPI Registration & Enumeration June 03, 2014

First registered as active Individual Practitioner in NPPES Database.

Patient & Community Reviews

Verified patient ratings, medical care experiences, and facility photos

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NPI Administrative Meta

NPI Number: 1063825446

Entity Type:

Individual Provider Physician, Nurse Practitioner, or Solo Healthcare Professional (Type 1 NPI)

Enumeration Date: June 03, 2014

Last Update: January 14, 2019

Sole Proprietor: No

Update or Correct Profile

Mailing Address

2214 N University St

Peoria, IL 616043221

Phone: 3096807669

Public Domain Record This profile contains public domain information published by CMS and NPPES under the Freedom of Information Act (FOIA).

⚠️ Medical Disclaimer

This directory listing is for informational purposes only and does not constitute medical advice, diagnosis, or physician endorsement. If you are experiencing a medical emergency, please call 911 immediately.