Healthcare Provider Details

I. General information

NPI: 1003842964
Provider Name (Legal Business Name): JOHN DEFOREST D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S DIXIE HWY
BEECHER IL
60401-3668
US

IV. Provider business mailing address

715 S DIXIE HWY
BEECHER IL
60401-3668
US

V. Phone/Fax

Practice location:
  • Phone: 708-946-9330
  • Fax: 708-946-2471
Mailing address:
  • Phone: 708-946-9330
  • Fax: 708-946-2471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number336051704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: