Healthcare Provider Details

I. General information

NPI: 1184115339
Provider Name (Legal Business Name): NAKEYA KHOZEMA DEWASWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date: 01/22/2019
Reactivation Date: 02/04/2019

III. Provider practice location address

2300 N EDWARD ST STE 2400
DECATUR IL
62526-4163
US

IV. Provider business mailing address

2300 N EDWARD ST STE 2400
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-2400
  • Fax: 217-876-2405
Mailing address:
  • Phone: 217-876-2400
  • Fax: 217-876-2405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036168990
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036168990
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: