Provider Demographics
NPI:1003067661
Name:ALTENBURGER, DANA L (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:L
Last Name:ALTENBURGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 W RAVINA PARK RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3067
Mailing Address - Country:US
Mailing Address - Phone:309-268-2657
Mailing Address - Fax:
Practice Address - Street 1:1304 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3558
Practice Address - Country:US
Practice Address - Phone:309-268-2657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.127294207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program