Provider Demographics
NPI:1003173345
Name:KENAMORE, BRUCE DELOZIER (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DELOZIER
Last Name:KENAMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DUPEE PL
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3402
Mailing Address - Country:US
Mailing Address - Phone:847-251-7603
Mailing Address - Fax:
Practice Address - Street 1:120 DUPEE PL
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3402
Practice Address - Country:US
Practice Address - Phone:847-251-7603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.0771777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine