Healthcare Provider Details

I. General information

NPI: 1053514646
Provider Name (Legal Business Name): THOMAS ROBERT DEKOJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E LAKE SHORE DRIVE SUITE 200
DECATUR IL
62521-3806
US

IV. Provider business mailing address

1750 E LAKE SHORE DRIVE SUITE 200
DECATUR IL
62521-3806
US

V. Phone/Fax

Practice location:
  • Phone: 217-428-6300
  • Fax: 217-428-6322
Mailing address:
  • Phone: 217-428-6300
  • Fax: 217-428-6322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036126490
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number261007
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: