Healthcare Provider Details

I. General information

NPI: 1366424061
Provider Name (Legal Business Name): DOUGLAS CRAIG MAIBENCO MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

IV. Provider business mailing address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

V. Phone/Fax

Practice location:
  • Phone: 217-329-1000
  • Fax: 217-329-1055
Mailing address:
  • Phone: 217-329-1000
  • Fax: 217-329-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036098825
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: