Healthcare Provider Details

I. General information

NPI: 1346242559
Provider Name (Legal Business Name): DAVID A DEBOER M.D., MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVENUE STE. 512
CHICAGO IL
60631
US

IV. Provider business mailing address

7447 W TALCOTT AVENUE STE. 512
CHICAGO IL
60631
US

V. Phone/Fax

Practice location:
  • Phone: 773-594-6460
  • Fax: 773-594-6473
Mailing address:
  • Phone: 773-594-6460
  • Fax: 773-594-6473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036073979
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: