Healthcare Provider Details

I. General information

NPI: 1386625895
Provider Name (Legal Business Name): JOHN THOMAS DOOLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST STE 660
PEORIA IL
61602-1060
US

IV. Provider business mailing address

6804 N STONECREST CT
PEORIA IL
61615-6620
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4670
  • Fax:
Mailing address:
  • Phone: 781-718-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number152376
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: