Provider Demographics
NPI:1083602551
Name:DOPPENBERG, EGON MR (MD)
Entity Type:Individual
Prefix:
First Name:EGON
Middle Name:MR
Last Name:DOPPENBERG
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 1:3551 HIGHLAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2160
Mailing Address - Country:US
Mailing Address - Phone:844-376-3876
Mailing Address - Fax:630-929-0633
Practice Address - Street 1:3551 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2100
Practice Address - Country:US
Practice Address - Phone:844-376-3876
Practice Address - Fax:630-929-0633
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36113314207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36113314Medicaid
IL36113314Medicaid
ILK17767Medicare ID - Type Unspecified