MARCUS ISMEDHI MUTIDJO APN
NPI 1063825446
Nurse Practitioner - Family in Peoria, IL

Q: What is Marcus Mutidjo's NPI number?

The NPI number for Marcus Mutidjo is 1063825446. It was assigned to this individual provider in the NPPES registry on June 3, 2014.

Q: What is Marcus Mutidjo's specialty?

The primary specialty registered for this NPI is Nurse Practitioner, specializing in Family, with taxonomy code 363LF0000X.

Q: When was this NPI record last updated?

The NPPES record for Marcus Mutidjo was last updated on January 14, 2019. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 7 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since June 03, 2014PECOS Enrolled

1701 W GARDEN ST, PEORIA, IL 61605(309) 680-7600(309) 680-7686 Get Directions Write a Review

NPPES record last updated: January 14, 2019. Verified against the NPPES registry weekly; last sync: August 02, 2026.

Record update history: Jan 14, 2019, Jan 12, 2019, Aug 28, 2018 and 1 more (4 updates tracked since 2018).

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About Marcus Ismedhi Mutidjo Apn NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

MARCUS ISMEDHI MUTIDJO APN (NPI 1063825446) is an individual family provider in Peoria, Illinois, licensed in Illinois (209016806) and active in the NPI registry since June 2014. He is enrolled in Medicare PECOS.

NPPES Registry Identity

NPI1063825446

Entity TypeIndividualMale

Primary Taxonomy363LF0000X

Provider Legal NameMARCUS ISMEDHI MUTIDJOCredential: APN

Location Address1701 W GARDEN STPeoria, IL 61605

Mailing Address2214 N University StPeoria, IL 61604-3221 · (309) 680-7669 · Fax (309) 681-8443

Phone(309) 680-7600

Fax(309) 680-7686

Sole ProprietorNo

Enumeration DateJune 3, 2014

Last NPPES UpdateJanuary 14, 20194 updates tracked since enumeration

✔ NPI 1063825446 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyNurse Practitioner · FamilyPhysician Assistants & Advanced Practice Nursing Providers

Taxonomy Code363LF0000X

License✔ Licensed in IL · 209016806

1701 W GARDEN ST, Peoria, IL 61605

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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Marcus Ismedhi Mutidjo Apn is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 61605 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient

$85.71 typical visit price

range $54.80 – $168.44

Typical copayment $21.42 (range $13.70 – $42.11)

Most-billed visit code 99203

Established Patient

$97.25 typical visit price

range $17.16 – $136.56

Typical copayment $24.31 (range $4.29 – $34.14)

Most-billed visit code 99214

Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Referred Medical Equipment & Supplies CMS DME claims

Durable medical equipment, devices and supplies this provider ordered from DME suppliers for patients, from Medicare fee-for-service claims.

Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service K0553

DME-Other DME · category DE017N

2 suppliers12 claims12 services$215.65 avg. paid by Medicare

Dollar amounts are the average Medicare paid the supplier per service. They are not the cost to the patient.

Other Providers at the Same Location NPPES 11

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

SARAH R KOSCICA MD

Family Medicine