Provider Demographics
NPI:1205832243
Name:DECASTRO, VENANCIO (MD)
Entity Type:Individual
Prefix:
First Name:VENANCIO
Middle Name:
Last Name:DECASTRO
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 1:600 W LAKE COOK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2089
Mailing Address - Country:US
Mailing Address - Phone:847-459-6495
Mailing Address - Fax:847-459-7929
Practice Address - Street 1:1430 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:SUITE 206
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-4830
Practice Address - Country:US
Practice Address - Phone:847-259-8226
Practice Address - Fax:847-392-5260
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
492730Medicare ID - Type Unspecified
ILC42368Medicare UPIN