Provider Demographics
NPI:1033167846
Name:VISCONTI, JOHN L (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:VISCONTI
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Gender:M
Credentials:DO
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Mailing Address - Street 1:4000 N ILLINOIS LN
Mailing Address - Street 2:STE C
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1969
Mailing Address - Country:US
Mailing Address - Phone:618-607-1340
Mailing Address - Fax:618-622-9724
Practice Address - Street 1:1418 CROSS ST
Practice Address - Street 2:DIV IM MEDICAL ONCOLOGY, STE 180
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:618-607-1340
Practice Address - Fax:618-622-9724
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-11-15
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Provider Licenses
StateLicense IDTaxonomies
IL036114479207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246964001Medicaid
ILENROLLEDMedicaid