Healthcare Provider Details

I. General information

NPI: 1073560751
Provider Name (Legal Business Name): THOMAS DEWEERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 11/07/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE #4800
NORMAL IL
61761
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-5900
  • Fax: 309-454-2820
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036084018
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: