Provider Demographics
NPI:1174501134
Name:DEMASK, JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DEMASK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:DEMASK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:201 S WABENA AVE
Mailing Address - Street 2:LOWER LEVEL B
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-8723
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-9128
Practice Address - Street 1:201 S WABENA AVE
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-8723
Practice Address - Country:US
Practice Address - Phone:815-467-1518
Practice Address - Fax:815-467-7419
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094869-1Medicaid
ILG49875Medicare UPIN
IL808070Medicare ID - Type Unspecified