Healthcare Provider Details

I. General information

NPI: 1306845045
Provider Name (Legal Business Name): MARK B DEYOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 N MAGNOLIA ST
ELMWOOD IL
61529-9602
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-742-6334
  • Fax: 309-647-6880
Mailing address:
  • Phone: 309-647-0201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036108454
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: