Provider Demographics
NPI:1285646588
Name:DETTORE, DIAMOND DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DIAMOND
Middle Name:DONALD
Last Name:DETTORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4705 WILLOW SPRINGS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6150
Mailing Address - Country:US
Mailing Address - Phone:708-795-1520
Mailing Address - Fax:708-795-1543
Practice Address - Street 1:4705 WILLOW SPRINGS RD STE 203
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6150
Practice Address - Country:US
Practice Address - Phone:708-795-1520
Practice Address - Fax:708-795-1543
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036039227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21608845OtherBCBS
IL21608845OtherBCBS
IL473161Medicare ID - Type Unspecified