Provider Demographics
NPI:1063496875
Name:BAXTER, WILLIAM (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BAXTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 W PRAIRIE DR
Mailing Address - Street 2:SUITE J
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3123
Mailing Address - Country:US
Mailing Address - Phone:815-895-3354
Mailing Address - Fax:815-895-3345
Practice Address - Street 1:920 W PRAIRIE DR
Practice Address - Street 2:SUITE J
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3123
Practice Address - Country:US
Practice Address - Phone:815-895-3354
Practice Address - Fax:815-895-3345
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094196Medicaid
IL036094196Medicaid
ILG53873Medicare UPIN