Healthcare Provider Details

I. General information

NPI: 1689886962
Provider Name (Legal Business Name): EVELENA ONTIVEROS MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MCKINLEY AVE STE 1
DECATUR IL
62526-5858
US

IV. Provider business mailing address

210 W MCKINLEY AVE STE 1
DECATUR IL
62526-5858
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6600
  • Fax: 217-876-6606
Mailing address:
  • Phone: 217-329-3232
  • Fax: 217-329-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036143984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: