Provider Demographics
NPI:1114971652
Name:DEMONT, BRUCE ANDERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ANDERSON
Last Name:DEMONT
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 1:315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-2671
Mailing Address - Country:US
Mailing Address - Phone:217-732-2161
Mailing Address - Fax:217-732-7481
Practice Address - Street 1:315 8TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-2671
Practice Address - Country:US
Practice Address - Phone:217-732-2161
Practice Address - Fax:217-732-7481
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG15403Medicare UPIN