Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 336051704 | IL |
NPI | 1003842964 |
---|---|
Provider Name | John Deforest |
First Address | Beecher, IL 60401-3668 |
Second Address | Beecher, IL 60401-3668 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2006 |
Last Update Date | 09/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036089998 | (05) | IL |
080154175 | RAILROAD MEDICARE (01) | |
9925692 | BC/BS (01) | IL |
G12826 | (02) | IL |