MEDICARE: DR. MARY P DEA DO

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	207R00000X	Internal Medicine Physician	036095029	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518951474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY P DEA DO

Provider Business Mailing Address
First Line	:	1804 N NAPER BLVD
Second Line	:	STE 103
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-8830
Country	:	US
Telephone Number	:	630-646-6200
Fax Number	:	630-428-4188

Provider Business Practice Location Address
First Line	:	1804 N NAPER BLVD
Second Line	:	STE 103
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-8830
Country	:	US
Telephone Number	:	630-646-6200
Fax Number	:	630-428-4188

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	10/17/2016

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