Provider Demographics
NPI:1053315861
Name:GRAVLIN, DEAN A (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:A
Last Name:GRAVLIN
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 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3045
Mailing Address - Country:US
Mailing Address - Phone:309-655-7888
Mailing Address - Fax:
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:STE 105
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3045
Practice Address - Country:US
Practice Address - Phone:309-655-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057930207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057930Medicaid
IL215840Medicare ID - Type Unspecified
IL036057930Medicaid