MEDICARE: DR. DEANNA FAE DUCOMB M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	0001405329	IL

General Provider Information

NPI Number	:	1124013107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEANNA FAE DUCOMB M.D.

Provider Business Mailing Address
First Line	:	1210 JEFFERSON ST
Second Line	:
City	:	CARLYLE
State	:	IL
Zip	:	62231-1323
Country	:	US
Telephone Number	:	618-594-2454
Fax Number	:	618-594-2404

Provider Business Practice Location Address
First Line	:	1210 JEFFERSON ST
Second Line	:
City	:	CARLYLE
State	:	IL
Zip	:	62231-1323
Country	:	US
Telephone Number	:	618-594-2454
Fax Number	:	618-594-2404

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	07/08/2007

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