Healthcare Provider Details

I. General information

NPI: 1386317949
Provider Name (Legal Business Name): DEJAN KOTUR DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 DEMPSTER ST STE 201
PARK RIDGE IL
60068-8426
US

IV. Provider business mailing address

2204 SHANNONDALE DR
LIBERTYVILLE IL
60048-1141
US

V. Phone/Fax

Practice location:
  • Phone: 708-374-3726
  • Fax:
Mailing address:
  • Phone: 708-374-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.012856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: